Author: Zawn Villines
Untreated or uncontrolled opioid use disorder can complicate medical procedures if a person wishes to avoid opioid anesthesia. However, healthcare professionals can offer pain relief without opioids, including opioid-free anesthesia (OFA) for surgery.
The anesthesia team will work with people with controlled opioid use disorder who are receiving methadone, buprenorphine, or extended-release naltrexone to avoid interruptions to treatment and complications.
Some people without a history of opioid use disorder may also opt for OFA when undergoing a medical procedure, especially if they have a family or personal history of addiction. In one study, 10% of people who had never taken opioids before continued using them after cancer surgery.
People who prefer opioid-free pain relief should address this with their healthcare team when discussing their treatment plan. If a person needs to undergo surgery, they may need to talk with an anesthesiologist about their options ahead of time.
Keep reading to learn more about the risks of anesthesia for people with opioid use disorder and the alternative pain management options they can use.
An opioid use disorder is the chronic use of opioids due to addiction. An individual continues using opioids in spite of serious potential or actual health or personal consequences.
It is possible to develop an opioid use disorder linked to several types of opioids. These include prescription opioids, such as morphine and codeine, as well as illegal opioids, such as heroin.
Drug overdoses have quadrupled since 1999, claiming nearly 500,000 lives. The leading cause of opioid overdoses is illegally manufactured fentanyl. Heroin is the next most common cause, just ahead of prescription opioids.
People may accidentally overdose on opioids as a result of:
- taking multiple opioids
- developing a tolerance that causes them to increase their dosage
- using legally prescribed opioids and illegal opioids at the same time
Several factors contribute to opioid use disorder. According to the Centers for Disease Control and Prevention (CDC), the first wave of opioid overdoses began in 1999 with the misuse of prescription opioids. In 2010, the use of heroin became a significant contributor to overdoses. In 2013, a new wave of deaths began due to drugs laced with the opioid fentanyl.
Opioid use disorder causes a person to become more tolerant of opioids over time. As a result, they must take a higher dosage to get the same effects they once got with a lower dosage. They also become dependent on opioids, which means that they need opioids just to feel normal.
When a person suddenly stops using opioids, it can trigger intense withdrawal symptoms that are both physically and psychologically painful. A desire to avoid withdrawal may keep a person using opioids even when they want to quit.
There are several risk factors for opioid use disorder, including psychiatric illness and childhood trauma. In combination with these, some potential high risk behaviors that can lead to opioid use disorder include:
- using prescription opioids for longer or at higher dosages than a doctor recommended
- using opioids to alleviate psychological pain
- the recreational use of opioids, including both prescription drugs and heroin
Traditional anesthesia often relies on an opioid to relieve pain. Without proper care, this poses the risk of relapse in people who have recovered from an opioid use disorder.
Opioids can damage the respiratory system and stop breathing. Therefore, in people who are actively misusing opioids, opioid-based anesthesia may intensify the risks.
However, this scenario is unlikely because surgeons will not likely operate on someone who has drugs in their system. To avoid this, people needing surgery will undergo treatment for opioid use disorder first.
Some other risks of opioid anesthesia in people who have or have had an opioid use disorder include:
- Tolerance: Opioids may not work as well to alleviate pain. Additional drugs or more opioids may, therefore, be necessary.
- Harmful medical side effects: These can include liver and heart damage, as well as dangerously low blood pressure.
- Withdrawal: A person may experience symptoms of withdrawal even if they have no prior history of opioid use disorder.
- Overdose: People with opioid use disorder may have a higher risk of overdose if they are using opioids at the time of anesthesia — for example, methadone to treat opioid use disorder. However, expert care minimizes the chances of overdose in such situations.
A person may also need pain management following surgery or another medical procedure. Using opioids at this stage poses similar risks. People should note, however, that there are several strategies in place to counter this risk and avoid relapse in these situation.
A history of opioid misuse does not have to mean that a person has to choose between opioids or no pain relief at all. Instead, they can work with their healthcare team or anesthesiologist to determine the right medications or combination of medications. Some treatment options include:
- Opioid sparing: This is the practice of using lower doses of opioids along with other pain relievers, and it is generally safest in people who are not actively using other opioids.
- Alternative pain management: Other drugs, such as ibuprofen, acetaminophen, gabapentin, and steroids, may ease pain. Doctors may use several drugs at once if the pain is severe.
- Local anesthetic: This is the practice of numbing a painful area. It works better for some types of pain than others. For example, it is possible to numb the teeth and gums for oral surgery.
- Postoperative pain: It is also important to manage pain after an operation. Many medications, such as acetaminophen and ibuprofen, can help with this. If a doctor believes that opioids are necessary, they may prescribe them at a low dosage and only for use in the hospital setting. The reason for this is that prescribing opioids at discharge increases the risk of misuse.
All this said, opioids are definitely still an option — in most cases, the preferred option — in surgical situations, even in people who may have opioid use disorder.
Several studies show that there are no negative outcomes when using opioid use disorder treatments, such as methadone, alongside surgeries, such as transplant surgeries.
In some cases, a doctor may need to delay or cancel a procedure, especially if a person is unexpectedly under the influence of opioids.
A 2020 article emphasizes that complete avoidance of opioids during anesthesia may not be necessary, even for people with opioid use disorder. The authors argue that although opioid use at hospital discharge is a primary contributor to opioid use disorder, opioid anesthesia during or immediately after surgery might not be.
A 2019 article also notes that there is currently insufficient research on the outcome for people who undergo surgical procedures using OFA.
For this reason, it is important to discuss the risks and benefits of treatment with a doctor. It is also essential to ensure that they are aware of any drugs a person currently takes, even if this use is unsafe or illegal.
Having opioid use disorder can lead to additional concern ahead of medical procedures. A person may worry that their opioid use disorder will worsen, they will experience overdose or anesthesia complications, or they will not be able to get adequate pain relief without opioids.
Experienced anesthesiologists know how to sedate someone safely without opioids, assess a person’s individual risk, and help them safely manage pain.
These professionals can only help if they understand the problem, though. So it is important for a person to be honest about their history and their treatment goals and to tell a doctor if they are currently using or under the influence of opioids.
Opioid use disorder is a medical problem, not a personal failing, and good doctors work with their patients to help them both manage pain and escape addiction. If anyone who contacts a healthcare professional for help finds them unsympathetic, it is advisable to try another healthcare professional instead, if possible.