Anesthesia Management in Patients with Opioid Tolerance
Treating pain in patients with existing opioid tolerance is an inherently difficult task. Considering the very real desire to alleviate severe pain, the inherent dangers of overprescribing, and the fact that such patients metabolize opioids at a rate that deviates from their opioid-naïve counterparts, physicians and caregivers are faced with a conundrum that is as much ethical as it is physiological. However, a variety of analgesic options as well as mindful management of opiate dosage can provide viable options for perioperative anesthesia in patients with existing opioid tolerance.
Research suggests that patients who are being maintained on a low daily dose of opioids or methadone/buprenorphine as part of their substance abuse recovery program can and should take their medication prior to surgery.[1] Additional administration of baseline medication is often unnecessary for the duration of the surgery itself. Patients who have a transdermal fentanyl patch should continue to wear it into surgery in order to avoid the lag in re-establishing baseline analgesic effects.[2],[3]
Intraoperative and post-surgical pain can be managed in a variety of ways. For select patients, parenteral opioid infusion can be used to alleviate pain, simply by increasing dosage of morphine or hydromorphine to account for tolerance.[4] For more extensive surgery, neuraxial anesthesia may be more appealing, given that it requires a lower dosage of anesthesia for the same analgesic effect.[5] However, research suggests that regional anesthesia should be administered when possible and particularly for surgery performed on the extremities, therefore reducing the requirement for general anesthesia in patients with opioid tolerance.[6] Local analgesic infusion may continue post-operatively via indwelling brachial plexus catheters and 48-hour disposable pumps.[6]
For long-term pain management, a pain specialist may be useful in helping with the gradual tapering of dosage. Oral opioid doses can be decreased gradually over three to seven days to baseline levels.[4] Furthermore, number of clinical visits, treatment duration, and use of mirtazapine or bupropion have been significantly associated with successful opioid tapering in patients with existing dependencies.[7]
References
[1] May JA, White HC, Leonard-White A, Warltier DC, Pagel PS: The patient recovering from alcohol or drug addiction: special issues for the anesthesiologist. Anesth Analg 2001; 92:160–1
[2] Sevarino FB, Ning T: Transdermal fentanyl for acute pain management, Acute Pain: Mechanisms and Management. Edited by Sinatra RS, Hord AH, Ginsberg B, Preble LM. St. Louis, Missouri, Mosby Yearbook, 1992, pp 364–9
[3] Sinatra RS, Hord AH, Ginsberg B, Caplan RA, Ready B, Oden RV, Matsen FA, Nessly ML, Olsson GL: Transdermal fentanyl for postoperative pain management. JAMA 1989; 261:1036–9
[4] Saberski L: Postoperative pain management for the patient with chronic pain, Acute Pain: Mechanisms and Management. Edited by Sinatra RS, Hord AH, Ginsberg B, Preble LM. St. Louis, Missouri, Mosby Yearbook, 1992, pp 422–31.
[5] Epidural Neural Blockade in Clinical Anesthesia and Management, 3rd edition. Edited by Cousins MJ, Bridenbaugh PO. Philadelphia, Lippincott–Raven, 1998.
[6] Hord AH: Postoperative analgesia in the opioid-dependent patient, Acute Pain: Mechanisms and Management. Edited by Sinatra RS, Hord AH, Ginsberg B, Preble LM. St. Louis, Missouri, Mosby Yearbook, 1992, pp 390–8.
[7] Zhou K, Jia P, Bhargava S, et al. Opioid tapering in patients with prescription opioid use disorder: A retrospective study. Scand J Pain. 2017;17:167-173. doi:10.1016/j.sjpain.2017.09.005.