Review article: Perioperative pain management of patients on methadone therapy

Abstract

P Pu ur rp po os se e: : Methadone, an opioid traditionally associated with the management of opioid addictive disorders, has been prescribed increasingly as an analgesic for the management of various chronic pain conditions. Despite the increasing popularity of methadone, most anesthesiologists are not familiar with its complex pharmacology. The purpose of this article is to review the pharmacology of methadone and to suggest a management algorithm for the perioperative care of methadone patients.S So ou ur rc ce e: : A Medline search was performed to obtain the published literature on the pharmacology of methadone and its use perioperatively.P Pr ri in nc ci ip pa al l f fi in nd di in ng gs s: : The complexity of methadone's pharmacology is characterized by a high inter-individual variability, a potential for interaction with other medications, and a long elimination half-life. The postoperative management of methadone patients may be difficult as they are often 'opioid-tolerant' but may be 'pain-intolerant'. For those patients who are taking part in methadone-maintenance programs, there is a potential for the problematic use of opioids or other substances. The management plan for patients taking methadone may differ depending on the type of surgery and the associated perioperative differences in fasting status and gastrointestinal function. In consideration of all the factors listed above, a management algorithm is outlined for the perioperative care of methadone patients.C Co on nc cl lu us si io on n: : Methadone is an opioid with complex properties, and a patient that is taking methadone can represent a unique challenge to the anesthesiologist. A good understanding of the pharmacology of methadone and of the type of patients on this medication will help to improve their perioperative care. Objectif

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

“…28 As is the case with other patients under chronic opioid therapy, these individuals taking heroine or methadone show a hyperalgesic state. Such patients may need surgery for a procedure that is related to their condition (abscess drainage, valve replacement) or because of a common condition (appendectomy, fracture, osteosynthesis, and so on).…”

“…Finally, the perioperative pain management in the patient specifically treated with methadone has been reviewed recently. 28 When a local or regional anesthesia technique can be performed and is suitable for the type of surgery and the patient, it should be preferred.…”

“…28 Comme les autres patients sous traitement opioïde continu, ces toxicomanes sous héroïne ou méthadone présentent un état d'hyperalgésie. Ces patients se présentent au bloc opératoire pour une chirurgie liée à leur état (drainage d'abcès, remplacement valvulaire par exemple) ou en raison d'une pathologie courante (appendicectomie, ostéosynthèse d'une fracture, etc.).…”

Behandling av akutte smerter under legemiddelassistert rehabilitering

“…Operasjonsdagen bør pasienten uansett valg av anestesiteknikk vanligvis få sin substitusjonsdose om morgenen (8). Hvis mulig, bør man benytte infiltrasjonsanestesi, perifere blokader eller epiduralanestesi for å redusere behovet for opioider.…”

Brief review: Perioperative management of the patient with chronic non-cancer pain

“…An abrupt discontinuation of methadone before surgery will make it difficult to provide adequate postoperative analgesia. 60 Another important preoperative consideration is that patients receiving higher doses (> 200 mg·day -1 ) of methadone may develop a prolonged Q-T interval, which is a risk factor for the development of Torsades de pointes. Therefore, a baseline electrocardiogram should be available for comparison 61 (Grade C).…”