Clinical Pain Advisor
Although there has been an increasing focus on addressing opioid use disorders (OUDs) in outpatient settings, there is a dearth of research regarding perioperative pain management in people with a history of OUD. Opioid tolerance and medications used for OUD treatment present significant challenges in this setting. “Patients with OUD have been shown to have lowered pain tolerance, increased sensitivity to pain, and comorbid chronic pain conditions compared [with] opioid-naive control groups” and the risk for relapse is a significant concern for those in recovery, according to a narrative review published in Anesthesia and Analgesia.1-3
Noting the lack of consensus regarding perioperative pain management in this population, the review authors offered clinical recommendations based on a review of the available literature. Key points pertaining to different patient subgroups are summarized below.
Patients with OUD in remission without medication treatment
Anxiety regarding surgery and postoperative pain, access to prescription opioids, and poorly controlled pain can lead to drug cravings and relapse, underscoring the importance of a thorough perioperative management plan for these patients.
Clinicians should consider regional anesthesia, adjunct nonopioid medications, and nonpharmacologic therapies to reduce the use of postoperative opioid analgesics.
If opioid analgesics are necessary, they should be prescribed for a limited time at the lowest effective dose.
Patients should be encouraged to connect with sponsors and/or peer support.
Patients with OUD on methadone treatmentThe daily outpatient methadone dose should be maintained during hospitalization. This dose is inadequate for acute pain relief, necessitating the use of additional medications and other pain management strategies.
Partial agonist opioid analgesics can lead to withdrawal symptoms and should be avoided.
Peripheral, regional, and neuraxial analgesia, or patient-controlled analgesia with opioids may be considered for moderate to severe pain.
Patients should be monitored for postoperative pain control and side effects such as euphoria and respiratory depression.
Discharge planning should include “communication with [outpatient treatment providers], including a letter verifying the last inpatient dose of methadone given, list of postdischarge medications, dosing directions, and the number of pills prescribed for pain,” wrote the review authors. “For high-risk patients, arranging a visiting nurse who can dispense medications, ensure opioid analgesic adherence, and monitor symptoms and side effects should be considered.”
Patients with OUD on buprenorphine-naloxone treatment
There are conflicting views and study results regarding acute pain management in this patient group, particularly regarding whether and when to discontinue buprenorphine-naloxone before surgery. For example, a protocol developed by the University of Michigan Health Systems recommends discontinuation of buprenorphine-naloxone and transition to short-acting opioids at least 5 days prior to surgery “to ensure opioid receptor availability for pain management purposes.”4
In contrast, the University of Kentucky Health Care System’s protocol suggests continuation of buprenorphine-naloxone along with the use of multimodal analgesia such as short-acting opioids, gabapentinoids, ketamine, and regional anesthesia. “Given the increased mortality rate immediately after discontinuing buprenorphine-naloxone, we strongly recommend continuing buprenorphine-naloxone preoperatively to ensure overall patient stability and prevent relapse from stopping and restarting the medication.” recommended the review.3
For pregnant patients on buprenorphine, there is consensus that treatment should be maintained to prevent withdrawal during delivery.
Patients should be monitored for pain as well as signs and symptoms of withdrawal, cravings, and anxiety. “Delivering an empathic approach to management including listening, reassurance, and transparency is crucial to help patients feel that they have some control and [that] their medical and psychological needs [are being] managed.”
Clinicians should collaborate with the provider who prescribed buprenorphine-naloxone and/or OUD inpatient consult team, and if buprenorphine-naloxone is discontinued before surgery, an appointment with the outpatient provider should be scheduled to ensure safe resumption of the drug following surgery.
Patients with OUD on naltrexone treatment
Patients receiving an oral formulation require a 72-hour washout period before surgery, and those on injectable naltrexone should ideally receive the last injection at least 4 weeks prior to surgery.
Postoperative pain management and relapse prevention in patients on naltrexone requires an individualized approach. Although research on the topic is limited, case reports suggest that general and regional anesthesia and nonopioid analgesia are effective strategies for perioperative pain control in this group.5,6
Consultation with a pain and addiction specialist should be considered, and the patient’s outpatient providers should be involved in a relapse prevention plan if opioids are required.
Patients should be closely monitored while hospitalized because of their potentially altered response to opioids.
Patients with current and untreated OUD
For individuals with current untreated opioid use, active withdrawal should be expected, and OUD and pain consultations are indicated to address postoperative recovery complications and increased pain sensitization commonly observed in these patients.
Available data suggest that “buprenorphine-naloxone and methadone are equally effective in treating signs and symptoms of withdrawal and are far superior to the alpha agonists such as clonidine.3,7 When choosing between methadone and buprenorphine-naloxone, the treatment team should consider patient preference, drug-drug interactions, side effect profile, and existing cardiac conduction problems (eg, increased corrected QT interval syndrome) and acute pain management options.”
Rather than tapering buprenorphine-naloxone or methadone after surgery, referral to an opioid treatment program should be arranged. Findings suggest that this approach is associated with greater reduction in illicit drug use and higher engagement in OUD treatment following surgery.8,9
In addition to these specific recommendations, most cases should generally involve discussion and planning with patients and their support persons; collaboration with patients’ mental healthcare and/or OUD provider; education regarding the safe use, storage, and disposal of opioids if applicable; and consideration of nasal naloxone prescription.
Clinical Pain Advisor spoke with the following experts to get their perspectives on managing perioperative pain in patients with OUD: review co-author E. Nalan Ward, MD, assistant professor of psychiatry at Harvard Medical School, and director of outpatient addiction services at the West End Clinic of Massachusetts General Hospital; and Timothy R. Deer, MD, DABPM, FIPP, clinical professor of anesthesiology and pain medicine at West Virginia University School of Medicine, and president and CEO of The Spine and Nerve Center of The Virginias.
Clinical Pain Advisor: What are some of the major challenges in perioperative pain management of patients with OUDs?
Dr Ward: It is complicated to provide adequate acute pain relief for patients who are opioid tolerant. Patients with OUD have additional challenges. In addition to acute pain management, patients need to be monitored for opioid withdrawal, cravings, and risk for relapse. This special population requires a multidisciplinary team approach including anesthesiologist, surgeon, internist, and addiction specialist. In addition, there is no consensus on how to manage acute pain in those who are on buprenorphine-naloxone.
Dr Deer: The challenges center around humanistic and appropriate treatment of pain with a careful attention to the risks, which can be quite high. The major challenges [pertain to] knowing when alternatives to opioids may be appropriate which allow us to avoid the opioid issues altogether. In the past, many surgeons have prescribed very high numbers of pills without any medical necessity. We must work on education and legislation to stop this practice.
Clinical Pain Advisor: How should clinicians approach these issues, including considerations for preoperative assessment, treatment planning, and postoperative care?
Dr Ward: It is imperative to approach the patient with OUD as a whole person. When choosing an acute pain management strategy, the risk for relapse should be a top priority consideration. A preoperative screening for OUD can aid in identifying those on medication treatment for OUD such as methadone, buprenorphine-naloxone, or injectable extended-release naltrexone. There is also an opportunity to identify individuals who are not connected to OUD treatment — the perioperative period can be “reachable moment” for some individuals.
Dr Deer: Preoperatively, the doctor should discuss expectations with the patient and the family. Options such as icing the wounds, local anesthetic infusions, and focusing on minimally invasive options should be considered. The discussion should focus on options such as perioperative nerve blocks, peripheral nerve stimulation, and the role of the caregiver in monitoring any controlled substances if they are felt to be a part of the program. In cases where opioids are felt to be part of the multimodal needs of the patient, a careful approach with limited amounts of drug and careful monitoring should be utilized.
Clinical Pain Advisor: What are remaining research needs regarding this topic?
Dr Ward: Despite their frequent overrepresentation in the inpatient general hospital setting, less is known about screening, assessment, and inpatient management of patients with OUD, and little has been studied on the optimal management of acute pain in these patients. There are relatively larger-scale data on the obstetric population with higher quality of evidence, but data are lacking for other surgery types regarding optimal dose of buprenorphine-naloxone during the perioperative period.
Dr Deer: Additional research is needed on preemptive pain methods to reduce the amount of postprocedural pain and on the use of nonopioid methods [such as] neuromodulation to reduce postoperative needs for pain control.
Clinical Pain Advisor: Are there any additional important takeaways for clinicians that you would like to mention?
Dr Deer: The important takeaway is that, while it is easy to reach for the prescription pad and give large amounts of postoperative opioids, in many patients this is a dangerous solution. The physician should carefully consider other multimodal risk mitigation strategies and give thought to best practices and potential life-saving actions.
1. Compton P, Charuvastra VC, Ling W. Pain intolerance in opioid-maintained former opiate addicts: effect of long-acting maintenance agent. Drug Alcohol Depend. 2001;63(2):139-146.
2. Wachholtz A, Gonzalez G. Co-morbid pain and opioid addiction: long term effect of opioid maintenance on acute pain. Drug Alcohol Depend. 2014;145:143-149.
3. Ward EN, Quaye AN-A, Wilens TE. Opioid use disorders: perioperative management of a special population. Anesth Analg. 2018;127:539-547.
4. Stern E. Buprenorphine and the anesthesia considerations: a literature review. Nurse Anesthesia Capstones. 2015.
5. Curatolo C, Trinh M. Challenges in the perioperative management of the patient receiving extended-release naltrexone. A A Case Rep. 2014;3(11):142-144.
6. Israel JS, Poore SO. The clinical conundrum of perioperative pain management in patients with opioid dependence: lessons from two cases. Plast Reconstr Surg. 2013;131(4):657e-658e.
7. Gowing L, Ali R, White J, Mbewe D. Buprenorphine for managing opioid withdrawal. Cochrane Database Syst Rev. 2017;2:CD002025.
8. Liebschutz JM, Crooks D, Herman D, et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med. 2014;174(8):1369-1376.
9. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644.