Perioperative Pain Management in Opioid Use Disorder
When your patients with opioid use disorder (OUD) develop pain due to medical illness or trauma, pain management can get tricky. When they seek pain control, they may be perceived as “drug seeking” in medical settings. Studies have shown that providing adequate pain management for these patients is a particular challenge (Department of Veterans Affairs, www.tinyurl.com/3cuzhpma; Koller G et al, Exp Opin Pharm 2019;20(16):1993–2005). Inadequate pain management, in turn, can cause various problems, including worsening substance use, mistrust of providers, and more post-surgical complications. This article will explore ways to manage pain effectively in patients with OUD, with a specific focus on the perioperative period. Some of these decisions will be made by your patients’ surgeons or primary care doctors, but you should be involved in advising them as they may not have much experience with this population.
Overall strategy
How should we manage OUD patients who are in acute pain related to surgery? In the past, the usual practice was to discontinue medication for addiction treatment (MAT), eg, discontinue buprenorphine (BUP) or methadone (MTD). The rationale for doing so was twofold. First, there was fear of overdosing patients who were already receiving opioids, and second, the presence of BUP or MTD could theoretically complicate anesthesia. However, faced with the growing opioid epidemic and the clear evidence supporting MAT, the American Society of Addiction Medicine (ASAM) issued an update to their guidelines and now recommend continuing MAT, and to supply additional analgesic treatment or alter MAT dosing, as indicated.
For pain management in OUD patients, ASAM recommends using opioids as needed, but emphasizes the use of non-opioid agents, like regional anesthesia, adjunctive non-opioid medications, and non-pharmacologic management. Typical non-opioid pain medications include acetaminophen, NSAIDs, gabapentinoids (eg, gabapentin and pregabalin), tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and ketamine (The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med 2020;14(2S):1–91). In my own practice, especially when a patient’s anxiety and insomnia are worsening pain perception, I favor the use of gabapentinoids, as well as hydroxyzine as needed. For insomnia, melatonin (3–9 mg), trazodone (50–100 mg), or low-dose doxepin (3–6 mg) are reasonable options. Remember, though these drugs are safer than opioids, they are not benign either; gabapentinoids have a risk of misuse (Evoy KE et al, Drugs 2021;81:125–156) and can increase the risk of opioid overdose (Bykov K et al, JAMA Netw Open 2020;3(12):e2031647). Tricyclics can increase the risk of cardiac arrhythmia.
If opioid analgesics are needed after surgery, choose short-acting full-agonist opioids like hydrocodone or oxycodone, prescribed for a limited time at the lowest effective dose. The CDC states that 3 days of opioid analgesics is usually sufficient, and the need for more than 7 days is rare for the treatment of non-chronic pain.
You should encourage your patients to keep in touch with community supports. A visiting nurse (or, in a pinch, a family member or friend) can help to secure and dispense prescribed opioid analgesics using a safe or locked pill box if necessary. If your patient has been actively using street drugs, be aware that hospital admissions will usually entail abstinence from illicit drugs. The potential hazard is that this forced abstinence can lead to decreased tolerance, and quickly returning to substance use after discharge can lead to overdose and death. Warn patients about the risk of overdose and give them a naloxone prescription.
Some anesthesiologists want patients to stop BUP or MTD before surgery if they anticipate the need for full-agonist opioids during the procedure. If the anesthesiologist requests this, you should stop the BUP or MTD the day before surgery. They can be resumed postoperatively when there is no longer a need for intravenous analgesia. Pre-surgery doses of these medications can be restarted if they were held for less than 2 to 3 days (Crotty K et al, J Addict Med 2020;14(2):99–112). Other anesthesiologists may advocate for continuing BUP at a reduced dose in order to balance intraoperative pain management with avoiding withdrawal and minimizing postoperative opioid agonists (Quay A and Zhang Y, Pain Medicine 2019;20(7):1395–1408). This is another reasonable approach, and the BUP dose can be lowered the day prior to surgery.
Patients with OUD on BUP or MTD
Your patients on BUP or MTD who have postoperative pain might receive add-on hydrocodone or oxycodone for management. Alternatively, you can choose to temporarily increase the dose of BUP or MTD. When you do this, you will probably have to increase the dosing frequency. Why? When used to prevent opioid cravings, both BUP and MTD are dosed once a day, because their craving-suppressant properties last for 24 to 36 hours. However, their analgesic effects typically only last for 6 to 8 hours. Therefore, dividing daily doses into 3 to 4 times daily can optimize their pain-relieving effect.
Another tricky aspect of BUP to remember is that it binds very strongly to opioid receptors—more strongly than most other opioids. Because of this, it can block opioid agonists from binding receptors, blunting their analgesic effects. If opioid agonists are already bound, the BUP can kick them off, sending the patient into opioid withdrawal. Therefore, you may need to discontinue BUP for a short time after surgery to allow for the use of full-agonist opioids. Be aware that as full agonists gradually displace BUP molecules from the mu receptor, there is an increased risk of oversedation and respiratory depression.
Patients with OUD on naltrexone
If your patient is taking oral naltrexone, make sure to stop the medication at least 72 hours before surgery to allow it to completely wash out. Injectable naltrexone should be stopped at least 4 weeks prior to surgery. These patients may switch to oral naltrexone, but they too should stop their medication 72 hours before surgery. It is important to keep in mind that patients on long-term naltrexone are at high risk for overdose once the naltrexone is stopped. This is because their opioid receptors have been starved of opioids for a long time and will be highly sensitive as a result. Monitor these patients closely for respiratory suppression and sedation when they start opioid agonists for pain. And don’t forget what may be obvious—namely, that these patients should be off opioids for 3 to 7 days before resuming either oral or extended-release naltrexone (Ward E et al, Anesth Analg 2018;127(2):539–547).
Patients with OUD in remission without medication
Patients in remission who are not receiving BUP, MTD, or naltrexone are particularly vulnerable to relapse if they are started on opioids for pain. Have a frank discussion of the risks and benefits of postoperative pain management well in advance, before surgery is scheduled. If postoperative opioid analgesics will be necessary, suggest self-help groups and close outpatient follow-up. Remember that during the postoperative period, the patient will be at risk for returning to use. Therefore, it is important to discuss the possibility of starting treatment with BUP, MTD, or injectable naltrexone immediately after surgery. BUP and MTD in particular could help ease pain and manage rebound opioid cravings.
Collaborative care
Optimal care for patients with OUD during the perioperative period requires a multidisciplinary approach. First and foremost, it is essential to collaborate with these patients on a comprehensive treatment plan. Many of them are aware of the risk that surgery entails and are justifiably worried about returning to opioid use. A bit of extra time spent on psychoeducation and construction of a safety plan can go a long way. In addition, I always involve anesthesiology, surgery, and internal medicine as early as possible. I make sure my colleagues know that opioid agonists are the standard of care for OUD treatment and that they should be continued until right before surgery and restarted as soon as possible after surgery. Patients with OUD are likely to have lowered pain tolerance, increased sensitivity to pain, increased tolerance to opioids, and comorbid chronic pain conditions. They may require higher than usual dosage and frequency of pain medications, and these expectations should be set as well.
CATR Verdict: Make sure your OUD patients get the right treatment before, during, and after surgery. Keep them on their medication for addiction treatment, and encourage your medical colleagues to use opioids as needed for pain sparingly.
Addiction TreatmentOverall strategy
How should we manage OUD patients who are in acute pain related to surgery? In the past, the usual practice was to discontinue medication for addiction treatment (MAT), eg, discontinue buprenorphine (BUP) or methadone (MTD). The rationale for doing so was twofold. First, there was fear of overdosing patients who were already receiving opioids, and second, the presence of BUP or MTD could theoretically complicate anesthesia. However, faced with the growing opioid epidemic and the clear evidence supporting MAT, the American Society of Addiction Medicine (ASAM) issued an update to their guidelines and now recommend continuing MAT, and to supply additional analgesic treatment or alter MAT dosing, as indicated.
For pain management in OUD patients, ASAM recommends using opioids as needed, but emphasizes the use of non-opioid agents, like regional anesthesia, adjunctive non-opioid medications, and non-pharmacologic management. Typical non-opioid pain medications include acetaminophen, NSAIDs, gabapentinoids (eg, gabapentin and pregabalin), tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and ketamine (The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder: 2020 Focused Update. J Addict Med 2020;14(2S):1–91). In my own practice, especially when a patient’s anxiety and insomnia are worsening pain perception, I favor the use of gabapentinoids, as well as hydroxyzine as needed. For insomnia, melatonin (3–9 mg), trazodone (50–100 mg), or low-dose doxepin (3–6 mg) are reasonable options. Remember, though these drugs are safer than opioids, they are not benign either; gabapentinoids have a risk of misuse (Evoy KE et al, Drugs 2021;81:125–156) and can increase the risk of opioid overdose (Bykov K et al, JAMA Netw Open 2020;3(12):e2031647). Tricyclics can increase the risk of cardiac arrhythmia.
If opioid analgesics are needed after surgery, choose short-acting full-agonist opioids like hydrocodone or oxycodone, prescribed for a limited time at the lowest effective dose. The CDC states that 3 days of opioid analgesics is usually sufficient, and the need for more than 7 days is rare for the treatment of non-chronic pain.
You should encourage your patients to keep in touch with community supports. A visiting nurse (or, in a pinch, a family member or friend) can help to secure and dispense prescribed opioid analgesics using a safe or locked pill box if necessary. If your patient has been actively using street drugs, be aware that hospital admissions will usually entail abstinence from illicit drugs. The potential hazard is that this forced abstinence can lead to decreased tolerance, and quickly returning to substance use after discharge can lead to overdose and death. Warn patients about the risk of overdose and give them a naloxone prescription.
Some anesthesiologists want patients to stop BUP or MTD before surgery if they anticipate the need for full-agonist opioids during the procedure. If the anesthesiologist requests this, you should stop the BUP or MTD the day before surgery. They can be resumed postoperatively when there is no longer a need for intravenous analgesia. Pre-surgery doses of these medications can be restarted if they were held for less than 2 to 3 days (Crotty K et al, J Addict Med 2020;14(2):99–112). Other anesthesiologists may advocate for continuing BUP at a reduced dose in order to balance intraoperative pain management with avoiding withdrawal and minimizing postoperative opioid agonists (Quay A and Zhang Y, Pain Medicine 2019;20(7):1395–1408). This is another reasonable approach, and the BUP dose can be lowered the day prior to surgery.
Patients with OUD on BUP or MTD
Your patients on BUP or MTD who have postoperative pain might receive add-on hydrocodone or oxycodone for management. Alternatively, you can choose to temporarily increase the dose of BUP or MTD. When you do this, you will probably have to increase the dosing frequency. Why? When used to prevent opioid cravings, both BUP and MTD are dosed once a day, because their craving-suppressant properties last for 24 to 36 hours. However, their analgesic effects typically only last for 6 to 8 hours. Therefore, dividing daily doses into 3 to 4 times daily can optimize their pain-relieving effect.
Another tricky aspect of BUP to remember is that it binds very strongly to opioid receptors—more strongly than most other opioids. Because of this, it can block opioid agonists from binding receptors, blunting their analgesic effects. If opioid agonists are already bound, the BUP can kick them off, sending the patient into opioid withdrawal. Therefore, you may need to discontinue BUP for a short time after surgery to allow for the use of full-agonist opioids. Be aware that as full agonists gradually displace BUP molecules from the mu receptor, there is an increased risk of oversedation and respiratory depression.
Patients with OUD on naltrexone
If your patient is taking oral naltrexone, make sure to stop the medication at least 72 hours before surgery to allow it to completely wash out. Injectable naltrexone should be stopped at least 4 weeks prior to surgery. These patients may switch to oral naltrexone, but they too should stop their medication 72 hours before surgery. It is important to keep in mind that patients on long-term naltrexone are at high risk for overdose once the naltrexone is stopped. This is because their opioid receptors have been starved of opioids for a long time and will be highly sensitive as a result. Monitor these patients closely for respiratory suppression and sedation when they start opioid agonists for pain. And don’t forget what may be obvious—namely, that these patients should be off opioids for 3 to 7 days before resuming either oral or extended-release naltrexone (Ward E et al, Anesth Analg 2018;127(2):539–547).
Patients with OUD in remission without medication
Patients in remission who are not receiving BUP, MTD, or naltrexone are particularly vulnerable to relapse if they are started on opioids for pain. Have a frank discussion of the risks and benefits of postoperative pain management well in advance, before surgery is scheduled. If postoperative opioid analgesics will be necessary, suggest self-help groups and close outpatient follow-up. Remember that during the postoperative period, the patient will be at risk for returning to use. Therefore, it is important to discuss the possibility of starting treatment with BUP, MTD, or injectable naltrexone immediately after surgery. BUP and MTD in particular could help ease pain and manage rebound opioid cravings.
Collaborative care
Optimal care for patients with OUD during the perioperative period requires a multidisciplinary approach. First and foremost, it is essential to collaborate with these patients on a comprehensive treatment plan. Many of them are aware of the risk that surgery entails and are justifiably worried about returning to opioid use. A bit of extra time spent on psychoeducation and construction of a safety plan can go a long way. In addition, I always involve anesthesiology, surgery, and internal medicine as early as possible. I make sure my colleagues know that opioid agonists are the standard of care for OUD treatment and that they should be continued until right before surgery and restarted as soon as possible after surgery. Patients with OUD are likely to have lowered pain tolerance, increased sensitivity to pain, increased tolerance to opioids, and comorbid chronic pain conditions. They may require higher than usual dosage and frequency of pain medications, and these expectations should be set as well.
CATR Verdict: Make sure your OUD patients get the right treatment before, during, and after surgery. Keep them on their medication for addiction treatment, and encourage your medical colleagues to use opioids as needed for pain sparingly.
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