American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy

Abstract

Enhanced recovery pathways have quickly become part of the standard of care for patients undergoing elective surgery, especially in North America and Europe. One of the central tenets of this multidisciplinary approach is the use of multimodal analgesia with opioid-sparing and even opioid-free anesthesia and analgesia. However, the current state is a historically high use of opioids for both appropriate and inappropriate reasons, and patients with chronic opioid use before their surgery represent a common, often difficult-to-manage population for the enhanced recovery providers and health care team at large. Furthermore, limited evidence and few proven successful protocols exist to guide providers caring for these at-risk patients throughout their elective surgical experience. Therefore, the fourth Perioperative Quality Initiative brought together an international team of multidisciplinary experts, including anesthesiologists, nurse anesthetists, surgeons, pain specialists, neurologists, nurses, and other experts with the objective of providing consensus recommendations. Specifically, the goal of this consensus document is to minimize opioid-related complications by providing expert-based consensus recommendations that reflect the strength of the medical evidence regarding: (1) the definition, categorization, and risk stratification of patients receiving opioids before surgery; (2) optimal perioperative treatment strategies for patients receiving preoperative opioids; and (3) optimal discharge and continuity of care management practices for patients receiving opioids preoperatively. The overarching theme of this document is to provide health care providers with guidance to reduce potentially avoidable opioid-related complications including opioid dependence (both physical and behavioral), disability, and death. Enhanced recovery programs attempt to incorporate best practices into pathways of care. By presenting the available evidence for perioperative management of patients on opioids, this consensus panel hopes to encourage further development of pathways specific to this high-risk group to mitigate the often unintentional iatrogenic and untoward effects of opioids and to improve perioperative outcomes.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

“…A maximally effective institutional strategy for perioperative pain management and opioid stewardship includes all phases and providers across this continuum. Though there is no definitive evidence-based regimen, effective multimodal analgesia requires institutional culture and protocols for pre-admission optimization, consistent use of regional anesthesia, routine scheduled administration of nonopioid analgesics and nonpharmacologic therapies, and reservation of systemic opioids to an "as needed" basis at doses tailored to expected pain and preexisting tolerance [15,18,33]. Figure 1 summarizes the recommended strategies at each phase of care, which will be discussed in greater detail.…”

“…Psychosocial comorbidities and behaviors that could negatively affect the patient's perioperative pain management and general recovery include anxiety, depression, frailty, and maladaptive coping strategies such as pain catastrophizing [15,18,52,[75][76][77][78]. Additionally, patients with chronic pain and/or history of a substance use disorder frequently experience anxiety regarding their perioperative pain management and/or risk of relapse [18].…”

“…Psychosocial comorbidities and behaviors that could negatively affect the patient's perioperative pain management and general recovery include anxiety, depression, frailty, and maladaptive coping strategies such as pain catastrophizing [15,18,52,[75][76][77][78]. Additionally, patients with chronic pain and/or history of a substance use disorder frequently experience anxiety regarding their perioperative pain management and/or risk of relapse [18]. While high-quality data is currently lacking to support specific pre-admission strategies for decreasing postoperative adverse events associated with mental health comorbidities, pilot studies and expert opinion support the integration of psychosocial optimization into the "prehabilitation" paradigm for surgical readiness [18,52,75,79].…”

“…Additionally, patients with chronic pain and/or history of a substance use disorder frequently experience anxiety regarding their perioperative pain management and/or risk of relapse [18]. While high-quality data is currently lacking to support specific pre-admission strategies for decreasing postoperative adverse events associated with mental health comorbidities, pilot studies and expert opinion support the integration of psychosocial optimization into the "prehabilitation" paradigm for surgical readiness [18,52,75,79]. Cognitive function, language barriers, health literacy, and other social determinants of health also significantly influence postoperative pain management and recovery [51,[80][81][82].…”

“…To this end, many organizations have offered guidance on components of their application. This has included general postoperative pain management [15][16][17], perioperative management of patients on preoperative opioids [18], surgery-specific guidelines [19][20][21][22][23][24], medication-specific recommendations [25,26], conceptual frameworks for opioid stewardship [27][28][29], collaborative postoperative opioid prescribing guidelines [30][31][32], statements on perioperative opioid use [33,34], legal opioid prescribing limits [35], and various quality measures for healthcare institutions [36][37][38]. Despite the multitude of recommendations available, a large proportion of surgical patients report inadequately treated pain and high rates of adverse events, alongside many institutions exhibiting overreliance on opioids and underutilization of multimodal strategies [2,39,40].…”