A practical, common problem in pain management is how to handle a patient already maintained on opioids and about to undergo surgery.
The American Pain Society recently released new guidelines for the perioperative and postoperative pain management.
The guidelines recommend that clinicians should counsel patients to continue regularly prescribed opioids during the preoperative period unless there is a plan to taper or discontinue opioids.
During preparation for surgery, a major problem clinicians may encounter is when the surgeon believes that the patient should reduce or even should stop their opioid medication before surgery.
This is a dangerous and clinically unnecessary belief and based on the false assumption that surgery may go better in an opioid-free state.
Unfortunately, an opioid-maintained pain patient who attempts to significantly lower or cease their opioid dosage just prior to surgery will throw their autonomic nervous, endocrine, and immunologic systems into a dysfunctional state.
Multiple physiologic abnormalities will result, including hypertension, tachycardia, leukocytosis, hypercortisolemia, and opioid withdrawal symptoms
These physiologic abnormalities may increase the risks of infection and poor recovery.
In addition, analgesia during surgery and after surgery may be difficult to achieve if the patient enters surgery in a pain flare and/or in a state of opioid withdrawal.
Opioids are effective pain management tools that can be used during the preoperative, intraoperative, and postoperative period
For patients who are on chronic opioid therapy prior to surgery, there are certain evidence-based approaches to provide adequate analgesia in the postoperative period. These include:
- Ensuring patients continue to take their regularly prescribed opioids prior to surgery unless there is a plan to taper or discontinue opioids
- Utilizing intravenous patient-controlled analgesia (PCA) for systemic analgesia when the parenteral route is needed
- Considering the amount of opioid the patient takes preoperatively and adjusting the postoperative doses of opioids accordingly to prevent inadequate pain management from “usual or standard” postoperative opioid doses.
My firm recommendation is that pain patients should remain on their regular opioid regimen up until the day and time of surgery. In addition, they should resume their regular opioid regimen as soon after surgery as possible.
Pain Relief During Surgery
As part of the perioperative pain management planning, I recommend a conversation with the surgeon and/or anesthesiologist prior to surgery.
Have the patient’s precise opioid regimen on hand when you converse with the surgeon or anesthesiologist. They will want to know the 24-hour opioid intake.
To me, the main points that the primary care physician needs to relay to the surgeon are that there is no medical reason to taper opioids before surgery, that the patient needs to be maintained on their usual opioids
Post-Operative Pain Plan
The surgical team and pain practitioner must be prepared to recommend or administer multiple strategies for analgesia in the 1 to 10 day period following surgery. No one strategy will work for every patient.
For postoperative pain, the chronic pain patient likely will need more than the usual dose that opioid-naïve patients normally receive.
The above is a critical point. Even though it seems obvious, too many surgeons think patients should taper off opioids so that they don’t need a high dose post-operatively. This is absolutely and completely wrong.
Only after surgery, if it is successful, should the patient be able to taper off opioids if they were being used to control pain that the surgery remediated.
The postoperative medications can be the same as what the patient was getting prior to surgery (or IV equivalent if NPO), and often in somewhat higher doses.
Here are some principles to follow in post-operative pain care:
- The patient’s regular opioid regimen should be reinstituted as soon as possible.
- Resumption of the patient’s regular pain regimen will usually depend, to a great extent, as to when the patient can take oral fluids and food.
- In those patients who cannot ingest oral medication, an injectable or other non-oral route of administration (patient-controlled analgesia) is necessary. My favorite post-operative opioids are injectable hydromorphone, meperidine, or morphine.
- Once oral medication can be taken, a short-acting opioid can be used.
- For knee, hip, shoulder, and back surgery, the patient can usually take oral medication quickly after surgery.
The key point in post-operative pain management is not relying only on opioids in the patients’ regular maintenance regimen.
Patients may become tolerant to their maintenance regimen, therefore post-operative pain relief may require a combination of agents not regularly used by the patient.
I have found that surgeons and anesthesiologists have 2 routine questions:
- What are my recommendations for post-operative pain relief?
- Will I resume routine pain care after the immediate post-operative period?
Surgeons must operate with the comfort of knowing that pain care will be available post-surgery.
As noted, chronic pain patients maintained on opioids often need a higher opioid dose than a patient who is opioid-naïve. This should not be considered analgesic resistance—if the patient has been taking 100 mg per day morphine, the patient is not likely to get adequate analgesia with a 1 to 2 mg IV or a lower oral dose
When adrenal insufficiency is suspected, an emergency serum cortisol level should be obtained. An injection of a corticosteroid such as methylprednisolone or hydrocortisone can be diagnostic if the patient obtains analgesia afterward. In addition to cortisol, serum levels of testosterone and possibly other hormones may drop and require supplementation in the post-operative period.
Chronic pain patients who are maintained on an opioid regimen require a variety of surgical interventions.
In preparation for surgery, the patient should be kept at a stable opioid dosage.
Reduction or cessation of opioids is ill-advised as any drop in opioid dosage may cause opioid withdrawal symptoms, emergence of suppressed pain, and dysfunction of the immune and endocrine systems that may increase surgical risks.
Pain control in the post-surgical period may require a short-acting opioid. Long-acting opioids are not recommended or labeled for use in the immediate post-operative period
Oral opioids are preferred in the postoperative period. However, since the patient may be unable to take oral fluids or medications in the immediate post-operative period, non-oral opioids may have to be administered.
The patient should resume their regular opioid maintenance regimen as soon after surgery as possible.