Higher postoperative opioid requirements due to chronic opioid and other adjuvant pain medication use.
Many patients have opioid tolerance and dependence; difficulty in managing acute pain.
- Tolerance: increasing amounts of opioids needed to provide comparable pain relief
- Physical dependence: withdrawal symptoms on abrupt cessation of the opioid
- Addiction: behavioral condition with recreational use of a substance in spite of harmful effects
- Pseudoaddiction: iatrogenic phenomenon in which patients are perceived by health care workers as displaying addictive behavior due to their increasing requests for pain medications in the setting of mistreatment or undertreatment of their pain
- Identify the patient on chronic opioid therapy early, preferably prior to the day of the surgery (e.g., during preadmission testing)
- Detailed history and thorough assessment including a detailed analgesic history of current medications, dosages, past favorable and adverse reactions to analgesics
- Would patients benefit from “medical optimization” by their pain medicine physician and/or by receiving preoperative nerve blocks or spinal injections to decrease their chronic pain? (For example, a patient with complex regional pain syndrome undergoing orthopedic surgery may benefit from preoperative sympathetic nerve blocks; a patient with lumbosacral radiculopathy may benefit from epidural steroid injections prior to joint surgery.)
- Develop a multimodal analgesic plan for the postoperative period in coordination with the pain service. Educate patient with respect to the multimodal analgesic plan of care, what to do in case of pain, expectations, and limitations. Ideally, include continuous regional anesthetic or epidural technique as well as a selective use of combination of NSAIDs, anticonvulsants, anxiolytics, antispasmodics, and antidepressants
- Do not underestimate the psychological dimension of pain. Psychological/psychiatric support might be useful
- Patients should continue all analgesics into the preoperative period including the day of surgery, unless contraindicated. Otherwise, the patient will have considerable rebound pain and withdrawal discomfort and pain due to absence of his or her routine analgesics
- Preemptive treatment with NSAIDs and anticonvulsants can be implemented the morning of the surgery to decrease postoperative opioid requirements and enhance analgesia. Examples:
- Gabapentin 300 mg PO before surgery, and then 300 mg PO q8 hours × 48 hours
- Celecoxib (Celebrex®) 400 mg PO before surgery, and then 200 mg PO q12 hours × 48 hours
- Acetaminophen 1,000 mg PO/IV before surgery, and then 1,000 mg PO q6–8 hours × 48 hours
- Anticonvulsants may reduce postoperative opioid requirements by up to 60% Mechanisms include:
- Stabilization of the neuronal membrane by blockage of pathologically active voltage-sensitive Na+ channels (carbamazepine, phenytoin, lamotrigine, topiramate)
- Blockage of voltage-dependent calcium channels (gabapentin, pregabalin)
- Inhibition of presynaptic release of excitatory neurotransmitters (gabapentin, lamotrigine)
- Enhancement of the activity of GABA receptors (topiramate)
- Implement regional part of multimodal analgesic plan: continuous perineural or epidural analgesia, neuraxial opioids
- Ensure patient has received adequate intraoperative doses of opioids, local anesthetics, and other adjuvant pain medications. Adjust doses to compensate for the patient’s opioid dependence
- Optimize the patient’s pain relief prior ...
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