Principles of perioperative pain management in opioid-tolerant patients
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
Titrate analgesic opioids to effect
Use non opioid and adjuvant medications
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 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