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11 Articles in Volume 16, Issue #2
Gender and the Pain Experience
Sex and Gender Differences In the Pain Experience
Medical Management of Diabetic Neuropathy
Comorbid Substance Use Disorders: Primer for Pain Management
Marijuana Use Disorder: Common and Often Untreated
Acupuncture: New Approach for Temporomandibular Disorders
Opioid-Maintained Patients Who Require Surgery
Natural Protein Points to New Inflammation Treatment
Lessons from the Murder Conviction of Dr. Hsiu-Ying “Lisa” Tseng
Zohydro vs Hysingla: What is the Difference in These Extended-Release Agents?
Letters to the Editor: Opioid Calculator, Testosterone for SCI

Opioid-Maintained Patients Who Require Surgery

When your patient requires surgery, many worry about pain management. Here are tips from an intractable pain clinic.

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.

Postoperative pain management key for patients with chronic pain who are undergoing 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

Pre-Surgery Preparation

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.

Non-Opioid Preparations

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:

  • 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. One example, is the use of a non-opioid drug, such as ibuprofen, which may be sufficient in some minor surgeries, such as dental extraction and biopsies.

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?

The answer to the second question must be that the pain practitioner will resume pain care as soon as the patient is able to leave the hospital or surgical facility. 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. This may even include their usual long-acting opioid as well as their short-acting, breakthrough opioids.

The tip-off is when the patient and/or family complain that no analgesia is forth-coming even from an injectable opioid or an opioid given by PCA. The solution to this problem may be to simply change opioids or raise dosage.

Hypothalamic-pituitary-adrenal suppression may occur with both chronic pain and opioid maintenance.3,4 The stress of surgery may be enough to put the HPA axis into a hazardous insufficiency state. Adequate serum levels of glucocorticoids are necessary for analgesia. Besides poor analgesia response, the patient may develop hypotension and tachycardia.

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 afterwards. In addition to cortisol, serum levels of testosterone and possibly other hormones may drop and require supplementation in the post-operative period.

Summary

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.5 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.

Last updated on: March 15, 2016
Continue Reading:
Lessons from the Murder Conviction of Dr. Hsiu-Ying “Lisa” Tseng

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