Perioperative Considerations for Patients with Opioid Use Disorder
Opioids are considered the standard of care in pain management in many situations, but their prescription for chronic non-malignant pain is increasingly controversial.1 Between 1999 and 2018, half a million deaths involving prescribed or illicit opioids were reported in the U.S., composing over 70% of all overdose-related deaths.2 Deaths related to opioid use have increased six times over since the turn of the century and continue to rise, exacerbated by the effects of the COVID-19 crisis and the subsequent economic recession.3 This “epidemic within a pandemic” has had a devastating impact on American health; the Overdose Mapping Application Program reported that the number of overdoses in 2020 rose by 18% in March, 29% in April, and 42% in May.3 The prevalence of opioid use disorder has significant implications for the health system, particularly for anesthesia providers who are tasked with providing crucial pain control in the perioperative period and maintaining their commitment to the Hippocratic Oath—“First, do no harm.”
Medical use of opioids during intraoperative and postoperative periods for patients with opioid use disorders is often contraindicated, and prescribing alternatives can be challenging for both patients and health care providers. Affected patients experience opioid tolerance and opioid-induced hyperalgesia, or an increased sensitivity to pain—a paradoxical consequence of sustained opioid use.4 Social stigma associated with drug use and addiction is an additional barrier to treatment and prevention mechanisms. Health care providers unaware of the risks of opioid-tolerance may prescribe high doses of synthetic opioids with life-threatening side effects, including cognitive, cardiac, and respiratory depression.
Gold standards for treating perioperative pain in patients with a history of opioid use disorder emphasize multimodal strategies combining psychiatric treatment, substance-use awareness and education, and opioid agonist therapeutics (OAT).5–7 Alternatives for reducing perioperative pain include use of non-opioid analgesics (e.g. NSAIDs and gabapentinoids), neuraxial or regional anesthesia, and targeted psychological evaluation.4 Low-dose opioids may be used in concert with short-acting narcotics, but treatment should be determined on an individual basis; some patients receiving variants of OAT such as methadone may require significantly higher doses of opioids. If opioids are deemed necessary, the American Association of Family Physicians recommends patients at high risk of opioid dependency should be strictly monitored before, during, and after their recovery period.1 Clinicians should also be aware of the social determinants of health that are related to opioid use disorder, as infection endemics disproportionately affect marginalized populations with medical and psychiatric co-morbidities.8 Individuals who face socioeconomic barriers to health care access (e.g., race- or class-based stigma, lack of insurance coverage, homelessness) are less likely to seek medical aid and therefore quality care may require increased sensitivity and empathy on the part of the provider.9,10
Finally, it bears noting that several recent studies and meta-analyses have found there may be no difference between NSAIDs and opioids in short-term and postoperative pain management in many situations.11–13 There is no single protocol for pain management in patients with opioid use disorder, but there are many ways in which pain can be holistically addressed without increasing the patient’s risk of opioid dependency, withdrawal symptoms, or overdose.
References
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2. Niles JK, Gudin J, Radcliff J, Kaufman HW. The Opioid Epidemic Within the COVID-19 Pandemic: Drug Testing in 2020. Population Health Management. 2021;24(S1):S-43-S-51. doi:10.1089/pop.2020.0230
3. Quaye ANA, Zhang Y. Perioperative Management of Buprenorphine: Solving the Conundrum. Pain Medicine. 2019;20(7):1395-1408. doi:10.1093/pm/pny217
4. Cornett EM, Kline RJ, Robichaux SL, et al. Comprehensive Perioperative Management Considerations in Patients Taking Methadone. Curr Pain Headache Rep. 2019;23(7):49. doi:10.1007/s11916-019-0783-z
5. Huxtable CA, Roberts LJ, Somogyi AA, Macintyre PE. Acute Pain Management in Opioid-Tolerant Patients: A Growing Challenge. Anaesth Intensive Care. 2011;39(5):804-823. doi:10.1177/0310057X1103900505
6. Hines S, Theodorou S, Williamson A, Fong D, Curry K. Management of acute pain in methadone maintenance therapy in-patients. Drug and Alcohol Review. 2008;27(5):519-523. doi:10.1080/09595230802245519
7. Harrison TK, Kornfeld H, Aggarwal AK, Lembke A. Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy. Anesthesiology Clinics. 2018;36(3):345-359. doi:10.1016/j.anclin.2018.04.002
8. Becker WC, Fiellin DA. When Epidemics Collide: Coronavirus Disease 2019 (COVID-19) and the Opioid Crisis. Annals of Internal Medicine. 2020;173(1):59-60. doi:10.7326/M20-1210
9. Kroll SL, Thayer JF, Williams DP, et al. Chronic non‐medical prescription opioid use and empathy for pain: Does pain make the difference? Psychophysiology. 2021;58(4). doi:10.1111/psyp.13776
10. Eukel HN, Skoy E, Werremeyer A, Burck S, Strand M. Changes in Pharmacists’ Perceptions After a Training in Opioid Misuse and Accidental Overdose Prevention. J Contin Educ Health Prof. 2019;39(1):7-12. doi:10.1097/CEH.0000000000000233
11. Smith SR, Deshpande BR, Collins JE, Katz JN, Losina E. Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review. Osteoarthritis and Cartilage. 2016;24(6):962-972. doi:10.1016/j.joca.2016.01.135
12. Uribe AA, Arbona FL, Flanigan DC, Kaeding CC, Palettas M, Bergese SD. Comparing the Efficacy of IV Ibuprofen and Ketorolac in the Management of Postoperative Pain Following Arthroscopic Knee Surgery. A Randomized Double-Blind Active Comparator Pilot Study. Front Surg. 2018;5:59. doi:10.3389/fsurg.2018.00059
13. Choi M, Wang L, Coroneos CJ, Voineskos SH, Paul J. Managing postoperative pain in adult outpatients: a systematic review and meta-analysis comparing codeine with NSAIDs. CMAJ. 2021;193(24):E895-E905. doi:10.1503/cmaj.201915