Acute Pain Management in Opioid-Tolerant Patients: A Growing Challenge

Abstract

In Australia and New Zealand, in parallel with other developed countries, the number of patients prescribed opioids on a long-term basis has grown rapidly over the last decade. The burden of chronic pain is more widely recognised and there has been an increase in the use of opioids for both cancer and non-cancer indications. While the prevalence of illicit opioid use has remained relatively stable, the diversion and abuse of prescription opioids has escalated, as has the number of individuals receiving methadone or buprenorphine pharmacotherapy for opioid addiction. As a result, the proportion of opioid-tolerant patients requiring acute pain management has increased, often presenting clinicians with greater challenges than those faced when treating the opioid-naïve. Treatment aims include effective relief of acute pain, prevention of drug withdrawal, assistance with any related social, psychiatric and behavioural issues, and ensuring continuity of long-term care. Pharmacological approaches incorporate the continuation of usual medications (or equivalent), short-term use of sometimes much higher than average doses of additional opioid, and prescription of non-opioid and adjuvant drugs, aiming to improve pain relief and attenuate opioid tolerance and/or opioid-induced hyperalgesia. Discharge planning should commence at an early stage and may involve the use of a 'Reverse Pain Ladder' aiming to limit duration of additional opioid use. Legislative requirements may restrict which drugs can be prescribed at the time of hospital discharge. At all stages, there should be appropriate and regular consultation and liaison with the patient, other treating teams and specialist services.

Nurses' competence in pain management in patients with opioid addiction: A cross-sectional survey study

“…Opioid addiction contributes to the development of opioid tolerance (Huxtable et al, 2011). Tolerance is defined as "a loss of analgesic potency that leads to ever-increasing dose requirements and decreasing effectiveness over time" (Ferri, 2013), causing patients with opioid misuse to require higher doses' of opioid in order to obtain pain relief.…”

Pain management strategies for patients on methadone maintenance therapy: a systematic review of the literature

“…The main effects include increased sensitivity to pain and decreased threshold of pain sensation, which together result in lowered pain tolerance 4. For patients on chronic MMT, effective acute pain management can be very difficult.…”

Management of Acute Pain in Patients on Treatment with Opioids

“…Chronic opioid exposure and the development of tolerance result in a rightward shift in the dose-response curve [12]. However, several reports have stressed that opioid administration may cause hyperalgesia events, with a reduction of the analgesic effect of the drug [16]. In this case, and unlike in tolerance phenomena, opioid-induced hyperalgesia leads to a decrease of the response at dose zero [17].…”

“…Patients should take their standard doses on the day of surgery, especially if they are taking high-dose long-acting opioids (e.g., methadone) to avoid withdrawal syndromes. They should be instructed not to take off their transdermal fentanyl patches on the day of the surgery [12,16]. Patients who have not taken their opioid dose should receive an equivalent load dose of morphine orally or, preferably, intravenously at the time of induction or during surgery [34].…”