Acute pain management for opioid dependent patients

Abstract

SummaryPatients requiring acute pain management may be opioid dependent as a result of either recreational or therapeutic opioid use, including those in opioid addiction programmes. Pain in these patients is often under-estimated and under-treated. In addiction, drug-seeking behaviour differentiates it from simple dependence. With few randomised controlled trials, current evidence predominantly consists of guidelines based on case reports, retrospective studies and expert opinion. Consensus recommendations include maintaining regular provision of the patient's pre-existing opioid requirement, with additional analgesia, ideally multimodal, in appropriate combinations of short-acting opioid (as required), local anaesthesia, and adjuvant anti-inflammatory analgesics and paracetamol. Patient controlled analgesia with higher bolus doses and shorter lock-out intervals is a recommended strategy. Transdermal opioid patches and implantable pumps will continue to deliver opioid, to which non-opioid and short-acting opioids may be added. Re-exposure to opioid is ideally avoided in previously addicted patients, but if not feasible, opioid therapy should be prescribed.

Why anesthesiologists need to care about the way chronic pain is managed

“…13 Nevertheless, use of PCA can lead to very challenging situations in the patient who has previously shown loss of control over their opioid medication. In this situation, a PCA needs to be used with care.…”

“…13 Toutefois, le recours à l'ACP peut créer des situations très difficiles pour un patient qui aurait, par le passé, perdu le contrôle sur ses médicaments opioïdes. Dans un tel cas, il faut faire attention lors de l'utilisation d'une ACP.…”

Acute Pain Management in Hospitalized Adult Patients with Opioid Dependence: A Narrative Review and Guide for Clinicians

“…30 In the case of patients on methadone as MAT, the methadone should be continued at the prescribed daily dose and additional short-acting opioid analgesics given to provide appropriate pain relief. 27,31 Because of opioid tolerance, patients receiving MAT often require increased and more frequent doses of short-acting opioid analgesics to achieve adequate pain control.…”

“…[14][15][16] To achieve analgesia as well as the reward effect, opioid dosage and/or frequency must be increased, strengthening the association between receipt of opioid and reward. Tolerance to the reward effect occurs quickly, whereas tolerance to respiratory depression occurs much more slowly.…”

Efficacy of Additives to Morphine Pumps in Post-Operative Pain Control of Addicted Patients

“…Acute pain management in opioid dependent patients remains a challenging and complex problem and it is becoming more common (1). In the acute pain setting, in addition to their daily opioid maintenance these patients need a multimodal approach (1).…”