Opioid-Maintained Patients Who Require Surgery
A practical, common problem in pain management is how to handle a patient already maintained on opioids and about to undergo surgery. During this time, anxiety may run high among the patient, their family, and the surgeon—the fear being, is the patient going to get adequate pain relief during and after the surgery.
Unfortunately, chronic pain patients with osteoarthritis, certain neuropathies, and trauma are more likely to need surgery than patients without chronic pain. Dental surgery is probably the most common procedure performed, followed by knee, hip, and shoulder joint surgery.
Seven of my own patients required surgery in the last 2 months, which inspired this article, including: dental extraction, cholecystectomy, tongue biopsy for carcinoma, oophorectomy, and cancer surgery for kidney, lung, and esophageal malignancies.
Each of these patients required preoperative preparation and coordination with the surgical team. 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.1
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. However, opioid use is also associated with postoperative nausea, vomiting, pruritus, urinary retention, and respiratory depression. 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.1 These include:
- Ensuring patients continue to take their regulalry 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.
Every pain patient and their family should be educated to maximize their general health before surgery. They may not be aware that both pain and opioids may suppress and impair their immunologic and endocrine systems, which must function maximally to have a successful surgery and avoid such complications as bleeding, infections, or poor healing.1,2
I emphasize to patients and families that:
- Proper sleep, diet, and exercise (as appropriate) is necessary in the month prior to elective surgery
- Dosage of all their medications including opioids should remain stable in the 30 days prior to surgery
- High protein, anti-inflammatory diet (Table 1), and dietary supplements that include vitamins B12 and D are highly recommended.
Surgeons usually recommend stopping vitamin E several days before surgery because of an increased risk of bleeding. If the patient is a poor or irregular eater, I recommend protein powders or bars, as well as a general dietary supplement such as brewer’s yeast, alfalfa, algae, or soy.
Pain Relief During Surgery
Every surgeon and anesthesiologist has their favorite analgesic medications they use during surgery and in the immediate post-operative period. After a review of the evidence, the APS formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacologic and nonpharmacologic modalities, organizational policies, and transition to outpatient care.
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 (just like continuing their diabetic, antihypertensive, and other medications), and give intravenous equivalents of their usual dose if the patient is nil per os (NPO) for a while.
The surgical team will then decide which opioid and which route of administration they will use during surgery and in the immediate post-operative period.
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 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. Also, if the patient is likely to be NPO for more than a couple of days, an alternative to IV dosing is a fentanyl patch.
Here are some principles to follow in post-operative pain care: