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 buprenorphine.
- 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 buprenorphine.
- 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. We can offer information at other sites.
- Avoid partial agonist opioids for analgesia.
For further advice contact BMC Sarnia at 519 337 5000 and ask to speak with a physician.
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