Perioperative pain management in the patient treated with opioids: Continuing Professional Development

Abstract

Purpose The objective of this continuing professional development module is to describe the perioperative anesthesia and pain management of patients taking opioids because of chronic pain or drug addiction. Principal findings The number of patients under opioid treatment is increasing. Pain management is problematic in these patients, because regular opioid intake is associated with mechanisms of tolerance and dependence. More recently, opioid-induced hyperalgesia phenomena have been brought to light. As a rule, the usual opioid dose should be administered with the appropriate conversions, and additional requirements should be anticipated because of the surgical procedure. Local and regional anesthesia, and multimodal analgesia are indicated whenever possible. For the patient addicted to heroin or other opioids, the perioperative period is not a suitable time to initiate weaning. Conclusion The physiological and pharmacological changes caused by chronic opioid intake must be understood in order to provide optimal pain management with respect to each individual and the type of procedure.Objectives of this continuing professional development module 1. To be aware of the importance of chronic pain and become familiar with the indications for opioids;2. To understand the pathophysiological mechanisms associated with chronic opioid consumption: tolerance, hyperalgesia, dependence, and other side effects; 3. To manage a patient during the perioperative period who is already treated with opioids; and 4. To understand and manage the case of a patient addicted to opioids.The prevalence of chronic pain is increasing, with approximately one in five individuals being affected.

Does the sedation regimen affect adverse events during procedural sedation and analgesia in injection drug users?

“…[10][11][12] When comparing IDUs to non-IDUs, they are felt to have different tolerances for sedative and analgesic medications. [13][14][15][16] PSA regimens that are safe and well tolerated in the non-IDU population may not be as successful in a patient who uses injection drugs. Currently, clinicians have little guidance in selecting a medication regimen that will allow safe and rapid sedation in the IDU population.…”

Do injection drug users have more adverse events during procedural sedation and analgesia for incision and drainage of cutaneous abscesses?

“…7,8 Peripheral intravenous access may be difficult 9 and pain tolerance may be decreased, requiring altered doses of analgesia. 10,11 We compared dosing of sedative and analgesic medications, adverse event (AE) rates, and recovery times in IDUs and non-IDUs undergoing PSA for incision and drainage of cutaneous abscesses.…”

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

“…For those individuals addicted to opioids, the perioperative period is not a time to initiate weaning. 14 The ANZAC Acute Pain Management: Scientific Evidence document provides a valuable management plan (http://www. anzca.edu.au/resources/college-publications/pdfs/Acute% 20Pain%20Management/books-and-publications/acutepain.…”