Opioid Use Disorders: Perioperative Management of a Special Population

Ward, E. Nalan; Quaye, Aurora; Wilens, Timothy E.

doi:10.1213/ane.0000000000003477

Cited by 101 publications

(94 citation statements)

References 66 publications

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“…Patients on a higher dose may develop a prolonged QT interval, which could lead to the development of torsade de pointes, especially if co-administered with drugs that inherently prolong QT ( 18 ). It is important to note that a daily methadone dose for the treatment of OUD is inadequate in providing acute pain relief, and additional medications and strategies are often required to mitigate the pain ( 19 ).…”

Section: Pharmacology Of Methadonementioning

confidence: 99%

Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review

Sritapan¹,

Clifford²,

Bautista³

2020

Balkan Med J

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The opioid epidemic has emerged as a major health and social problem over the last few decades. An increasing number of patients with opioid use disorder are presenting for perioperative management. These patients are either on buprenorphine or methadone for the maintenance and treatment of opioid addiction or chronic pain. In the settings of acute pain, the optimal management of patients with opioid use disorder is challenging, and recovery can be jeopardized secondary to the unique pharmacology of these agents. The purpose of this narrative review is to summarize the existing studies on the perioperative management of patients who are using buprenorphine and methadone and provide guidance for the management of patients with opioid use disorder during the perioperative period.

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Section: Pharmacology Of Methadonementioning

confidence: 99%

Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review

Sritapan¹,

Clifford²,

Bautista³

2020

Balkan Med J

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“…Until now, inadequate pain management is the main impetus for the perioperative discontinuation of buprenorphine. Recent evidence suggests that its perioperative discontinuation may hinder harm reduction by destabilising patients with OUD 5. For example, transitioning a patient off buprenorphine to a full agonist opioid will permit free access to opioid receptors for the purposes of analgesia, but will not address the OUD that may worsen as a result 5.…”

Section: Introductionmentioning

confidence: 99%

“…Recent evidence suggests that its perioperative discontinuation may hinder harm reduction by destabilising patients with OUD 5. For example, transitioning a patient off buprenorphine to a full agonist opioid will permit free access to opioid receptors for the purposes of analgesia, but will not address the OUD that may worsen as a result 5. Emerging evidence suggests that certain subsets of patients are less likely to experience deterioration of their OUD6 7 no matter which strategy is pursued (continue or discontinue).…”

Section: Introductionmentioning

confidence: 99%

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): protocol of a practice advisory for the perioperative management of buprenorphine using a modified Delphi process

et al. 2019

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IntroductionThe ongoing opioid epidemic has necessitated increasing prescriptions of buprenorphine, which is an evidence-based treatment for opioid use disorder, and also shown to reduce harms associated with unsafe opioid administration. A systematic review of perioperative management strategies for patients taking buprenorphine concluded that there was little guidance for managing buprenorphine perioperatively. The aim of this project is to develop consensus guidelines on the optimal perioperative management strategies for this group of patients. In this paper, we present the design for a modified Delphi technique that will be used to gain consensus among patients and multidisciplinary experts in addiction, pain, community and perioperative medicine.Methods and analysisA national panel of experts identified by perioperative, pain and/or addiction systematic review authorship established an international profile in perioperative, pain and/or addiction research, community clinical excellence and by peer referral. A steering group will develop the first round with a list of indications to be rated by the panel of national experts, patients and allied healthcare professionals. In round 1, the expert panel will rate the appropriateness of each individual item and provide additional suggestions for revisions, additions or deletions. The definition of consensus will be set a priori. Consensus will be gauged for both appropriateness and inappropriateness of treatment strategies. Where an agreement is not reached and items are suggested for addition/deletion/modification, round 2 will take place over teleconference in order to obtain consensus.Ethics and disseminationInstitutional research ethics board provided a waiver for this modified Delphi protocol. We plan on developing a national guideline for the management of patients taking buprenorphine in the perioperative period that will be generalisable across three sets of preoperative diagnoses including opioid use disorder and/or co-occurring pain disorders. The findings will be published in peer-reviewed publications and conference presentations.

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“…Managing severe pain in the emergency room, and the peri-operative period, is complex. While opioid analgesics remain the mainstay of treatment for severe pain, increasing numbers of patients with chronic pain states and opioid dependence can challenge the ability of traditional analgesic regimes to provide adequate pain control [1–4]. Opioid-induced hyperalgesia and analgesic tolerance are frequent drivers of diminished pain control and dose escalations in the hospital setting [5, 6].…”

Section: Introductionmentioning

confidence: 99%

KEA-1010, a ketamine ester analogue, retains analgesic and sedative potency but is devoid of Psychomimetic effects

Harvey

Sleigh

Voss

et al. 2019

BMC Pharmacol Toxicol

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BackgroundKetamine, a widely used anaesthetic and analgesic agent, is known to improve the analgesic efficacy of opioids and to attenuate central sensitisation and opioid-induced hyperalgesia. Clinical use is, however, curtailed by unwanted psychomimetic effects thought to be mediated by N-methyl-D-aspartate (NMDA) receptor antagonism. KEA-1010, a ketamine ester-analogue designed for rapid offset of hypnosis through hydrolysis mediated break-down, has been shown to result in short duration sedation yet prolonged attenuation of nociceptive responses in animal models. Here we report on behavioural effects following KEA-1010 administration to rodents.MethodsKEA-1010 was compared with racemic ketamine in its ability to produce loss of righting reflex following intravenous injection in rats. Analgesic activity was assessed in thermal tail flick latency (TFL) and paw incision models when injected acutely and when co-administered with fentanyl. Tail flick analgesic assessment was further undertaken in morphine tolerant rats. Behavioural aberration was assessed following intravenous injection in rats undergoing TFL assessment and in auditory pre-pulse inhibition models.ResultsKEA-1010 demonstrated an ED50 similar to ketamine for loss of righting reflex following bolus intravenous injection (KEA-1010 11.4 mg/kg [95% CI 10.6 to 12.3]; ketamine (racemic) 9.6 mg/kg [95% CI 8.5–10.9]). Duration of hypnosis was four-fold shorter in KEA-1010 treated animals. KEA-1010 prolonged thermal tail flick responses comparably with ketamine when administered de novo, and augmented morphine-induced prolongation of tail flick when administered acutely. The analgesic effect of KEA-1010 on thermal tail flick was preserved in opioid tolerant rats. KEA-1010 resulted in increased paw-withdrawal thresholds in a rat paw incision model, similar in magnitude yet more persistent than that seen with fentanyl injection, and additive when co-administered with fentanyl. In contrast to ketamine, behavioural aberration following KEA-1010 injection was largely absent and no pre-pulse inhibition to acoustic startle was observed following KEA-1010 administration in rats.ConclusionsKEA-1010 provides antinociceptive efficacy in acute thermal and mechanical pain models that augments standard opioid analgesia and is preserved in opioid tolerant rodents. The NMDA channel affinity and psychomimetic signature of the parent compound ketamine is largely absent for KEA-1010.

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Opioid Use Disorders: Perioperative Management of a Special Population

Cited by 101 publications

References 66 publications

Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review

Perioperative Management of Patients on Buprenorphine and Methadone: A Narrative Review

Perioperative Pain and Addiction Interdisciplinary Network (PAIN): protocol of a practice advisory for the perioperative management of buprenorphine using a modified Delphi process

KEA-1010, a ketamine ester analogue, retains analgesic and sedative potency but is devoid of Psychomimetic effects

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