Principles of perioperative pain management in opioid-tolerant patients

Preop:

Reassure the patient that their opioid maintenance will not prevent adequate perioperative analgesia

Ensure the maintenance opioid is taken on the day of surgery – methadone or Suboxone

Liaise with BMC. We will usually arrange a take home dose of their maintenance medication for the day of surgery

Intraoperative:

Titrate analgesic opioids to effect

Use non opioid and  adjuvant medications

Postoperative analgesia:

Continue maintenance opioid at preop dose – methadone or Suboxone

Incremental opioid analgesic doses will likely be higher (including PCA) than in the opioid naive

Much higher than expected total daily doses may be required

Titration to effect for each patient is important

Monitor pain, functional activity and sedation

Expect the need for more frequent review and adjustment of dosing

Adjuvant medications are probably helpful

Regional analgesia is useful 

Prevention of withdrawal:

Continue existing opioid maintenance – BMC will write these orders at Bluewater Health. At other hospitals temporary exemptions for methadone allow for physicians to continue maintenance methadone. Call office of Controlled Substances 1 866 358 0453

Avoid partial agonist opioids

Adapted from: Huxtable C A et al. Acute pain management in opioid-tolerant patients: a growing challenge. Anesthesia and Intensive Care 2011; 39:804-823