Managing Prolonged Pain After Surgery: Examining the Role of Opioids

A notable minority of patients experience persistent postsurgical pain and some of these patients consequently have prolonged exposure to opioids. Risk factors for prolonged opioid use after surgery include preoperative opioid use, anxiety, substance abuse, and alcohol abuse. The window to intervene and potentially prevent persistent opioid use after surgery is short and may best be accomplished by both surgeon and anesthesiologist working together. Anesthesiologists in particular are well positioned in the perioperative surgical home model to affect multiple aspects of the perioperative experience, including tailoring intraoperative medications and providing consultation for possible discharge analgesic regimens that can help minimize opioid use. Multimodal analgesia protocols reduce opioid consumption and thereby reduce exposure to opioids and theoretically the risk of persistent use. Regional anesthesia and analgesia techniques also reduce opioid consumption. Although many patients will recover without difficulty, the small minority who do not should receive customized care which may involve multiple office visits or consultation of a pain specialist. Enhanced recovery pathways are useful in optimizing outcomes after surgery.     

Perioperative Schmerztherapie bei opioidgewöhnten Patienten

In this review article the special anesthesiological problems of opioid tolerance and surgical interventions will be presented. These affect patients with a long-term opioid therapy of chronic pain, addicts with long-term substitution therapy and addicts with current or previous heroin addiction (“clean”). For all patient groups a guarantee of continuous and adequate analgesia (avoidance of fear and increasing patient compliance), exploiting suitable regional anesthesia or regional analgesia procedures when possible, and prevention of a physical opioid withdrawal syndrome have utmost priority. The necessary optimization of perioperative pain therapy only succeeds when based on a thorough preoperative examination of the clinical history which subtly inquires into the drug taking habits with respect to opioids and associated medications. Systemic and/or regional analgesia procedures are possible. Regional procedures are more effective for analgesia. Systemic analgesia procedures do not basically differ from those routinely used for patients without opioid tolerance. However, higher doses of opioids are necessary as well as individual titration according to needs. Special conditions apply to patients previously addicted to opioids (clean) when they are to be operated on. Non-opioids are sufficiently effective for low level pain and opiates can be avoided. Opioid therapy with inclusion of a non-opioid is necessary following major operations or for severe postoperative pain, even as i.v. patient-controlled analgesia (i.v. PCA) if needed. For these patients a relapse to addiction can be provoked by insufficient administration of analgesics, not by pain management including opioids.     

Acute pain therapy for non opioid-naive patients

Patients used to opioids belong to 2 groups: patients under opioid therapy due to tumor pain or chronic non malignant pain and, second, opioid addicts with current uncontrolled abuse, under substitution therapy or former opioid addicts ("clean"). Perioperatively these patients are difficult to manage because of the complex medical as well as psychosocial factors. Despite these problems, these patients have a right to receive sufficient perioperative pain therapy and this should not be withheld. Due to the lack of controlled studies this review summarizes standardized examples and alternatives in the acute pain treatment of patients using opioids. Early interdisciplinary cooperation, prevention of withdrawal through substitution of opioids and alternative treatment strategies like regional analgesia or ketamine as well as carefully titration of opioids are the essential components of the treatment of these patients. Furthermore, these patients require a clear and empathic guidance by medical and nursing staff.     

Perioperative management of the chronic pain patient

The chronic pain patient has certain distinctive features important for her/his perioperative management. Altered opioid sensitivity and behavior are the major points to be considered. The pre-anesthetic visit should therefore include questions regarding chronic pain and regular use of analgesics and coanalgesics, among others. Although a number of characteristics-including increased opioid demand, underreporting of pain, and non-compliance--are known, only a few specific recommendations are available, viz. adequate increase of opioid dose for analgesia, continuation of pre-operative opioids and coanalgesics to prevent withdrawal, and intensive education to strengthen the patient's coping potential. No differences between specific techniques for post-operative analgesia (e.g. systemic, patient-controlled or regional analgesia) have been shown so far.     

Analgesia for the parturient with chronic nonmalignant pain

The prevalence of chronic pain, including but not limited to back, leg, and pelvic pain, is substantial during the peripartum period. Such pain may affect maternal and fetal outcomes. Therefore, obstetric anesthesiologists should be familiar with the analgesia provided to patients with chronic pain as well as any history of opioid dependence or substance abuse. We systematically searched PubMed and the Cochrane databases for all reports published on perioperative management of parturients with chronic pain. Abrupt cessation of opioid maintenance treatment or the use of partial opioid agonists-antagonists (commonly prescribed to parturients) is likely to cause acute withdrawal and uncontrolled pain that could lead to preterm labor, fetal abnormalities, or even fetal demise. Parturients receiving opioid maintenance therapy typically require higher doses of opioids for pain relief because they have a lower pain threshold. However, complying with such requests for higher doses may further compromise patient, fetus, and neonate safety. Opioid agonist-antagonist drugs, except buprenorphine, should be avoided in patients receiving maintenance opioid therapy. Drugs such as nalbuphine, butorphanol, pentazocine, and tramadol may incite severe withdrawal. Similarly, buprenorphine should not be offered for acute pain management to a parturient who is receiving methadone maintenance. Individualized plans of prenatal and neonatal care as well as breastfeeding are important during hospital admission of those dependent on opioids. Parturients who have implanted pain management devices such as spinal cord stimulators (SCSs) or intrathecal pumps (ITPs) should receive particular attention from anesthesiologists. Localizing the SCS lead or the ITP catheter positions is essential for safe administration of axial analgesia. Fluoroscopic images of the SCS leads and ITP catheters obtained during implantation are routinely available and should be acquired to avoid damage to these leads. Ultrasonography may be used for mapping the lead or catheter if fluoroscopic images cannot be obtained. The substantial prevalence of chronic pain in the obstetric population suggests the need for further research. Investigations should focus on gaining a better understanding of chronic pain during pregnancy, labor, and delivery so as to develop effective anesthetic and analgesic strategies.     

Perioperative pain management in the patient treated with opioids: Continuing Professional Development

Purpose

The objective of this continuing professional development module is to describe the perioperative anesthesia and pain management of patients taking opioids because of chronic pain or drug addiction.

Principal findings

The number of patients under opioid treatment is increasing. Pain management is problematic in these patients, because regular opioid intake is associated with mechanisms of tolerance and dependence. More recently, opioid-induced hyperalgesia phenomena have been brought to light. As a rule, the usual opioid dose should be administered with the appropriate conversions, and additional requirements should be anticipated because of the surgical procedure. Local and regional anesthesia, and multimodal analgesia are indicated whenever possible. For the patient addicted to heroin or other opioids, the perioperative period is not a suitable time to initiate weaning.

Conclusion

The physiological and pharmacological changes caused by chronic opioid intake must be understood in order to provide optimal pain management with respect to each individual and the type of procedure.     

Acute perioperative pain in neonates: An evidence-based review of neurophysiology and management

Current literature lacks systematic data on acute perioperative pain management in neonates and mainly focuses only on procedural pain management. In the current review, the neurophysiological basis of neonatal pain perception and the role of different analgesic drugs and techniques in perioperative pain management in neonates are systematically reviewed. Intravenous opioids such as morphine or fentanyl as either intermittent bolus or continuous infusion remain the most common modality for the treatment of perioperative pain. Paracetamol has a promising role in decreasing opioid requirement. However, routine use of ketorolac or other nonsteroidal anti-inflammatory drugs is not usually recommended. Epidural analgesia is safe in experienced hands and provides several benefits over systemic opioids such as early extubation and early return of bowel function.     

Editorial Commentary: Hip Preservation and Opioids

Approximately one-third of patients undergoing arthroscopic hip preservation surgery for femoroacetabular impingement syndrome and labral tears are on preoperative opioid medications. The single most important predictor for prolonged chronic postoperative opioid use is preoperative use. Despite the well-documented high success rates in nonarthritic, nondysplastic individuals undergoing hip arthroscopy, up to half of those individuals on preoperative opioids may still be on opioids at 1 to 2 years of follow-up. Mental wellness disorders (e.g., depression, anxiety, substance abuse) significantly impact both pre- and postoperative pain, function, and activity in nearly all joint and general health outcome measures. Multimodal pain management strategies have shown excellent reduction in perioperative opioid utilization. Intraoperative techniques should strive for comprehensive true hip preservation: labral repair, accurate cam/pincer morphology correction, and routine capsular management. Objective, quantitative pain threshold and pain tolerance measurements may improve treatment decision-making, with better prediction of surgical outcomes. Future personalized health care may use a single individual’s mu opioid receptor (OPRM-1 gene) and a number of other genetic markers for pain management to reduce the need for traditional opioid medications. Is opioid-free hip arthroscopy possible? Absolutely. Will the opioid epidemic end? Yes, but we have a lot of work to do.     

Knowledge of palliative care which a surgeon should know

The Japanese who are in a hospice or a palliative care ward recently, and pass away are increasing in number. However, the present condition is that most pass away in a general ward. In Japan, since a surgeon is concerned in many cases to terminal care, in addition to the operation method and perioperative management, has to learn the knowledge of palliative care. Terminally ill cancer patients experience the severe pain which takes about 70% or more of patients painkilling by opioid with various pain, such as loss of appetite, general malaise, and insomnia, in many cases. For this reason, in especially terminally ill cancer patient's palliative care, sharp pain medical treatment is important. A surgeon has to learn about how to use the concept of WHO Cancer Pain Relief Program and opioid rotation, and adjuvant analgesics. To spend life whose terminally ill cancer patients seeming is the person, the surgeon should do palliative care.     

Management of perioperative pain in patients chronically consuming opioids

BACKGROUND: The prevalence of licit and illicit opioid use is growing, and a greater percentage of chronically opioid-consuming patients are presenting for surgery. These patients can be expected to experience increased postoperative pain, greater postoperative opioid consumption, and prolonged use of healthcare resources for managing their pain. METHODS: Achieving adequate pain control in these patients can be challenging because commonly used strategies for alleviating postoperative pain may have diminished effectiveness. We explore the prevalence and characteristics of opioid use in the United States and discuss its impact on the perioperative management of pain. We examine mechanistically why adequate perioperative pain control in chronically opioid-consuming patients may be difficult. CONCLUSIONS: We present strategies for providing adequate analgesia to these patients that include the optimal use of opioids, adjuvant medications, and regional anesthetic techniques.     

阿片类药物诱导的痛觉过敏研究新动向

背景 阿片类药物是把双刃剑,在围手术期镇痛和慢性疼痛治疗的广泛应用中,可同时诱发机体对疼痛的敏感性增加,即阿片类药物诱发的痛觉过敏(opioid-induced hyperalgesia,OIH)这一与镇痛自相矛盾的现象. 目的 综述OIH的研究进展,期望进一步理解OIH,从而促进临床工作中更加合理地应用阿片类药物. 内容 从分类、诊断、产生机制以及防治措施等方面对OIH的研究进展进行综述. 趋向 目前对OIH的诊断、产生机制及防治措施等多个方面尚未完全清楚,需要更加重视并进一步加以研究,以期深入地了解OIH,从而为临床管理提供更好的指导.     

Tumordurchbruchschmerz

The pharmacotherapy of tumor pain has two main aims: to deliver an adequate basic analgesia using long-term retarded opioid medication and an effective treatment of tumor breakthrough pain using rapidly effective non-retarded opioids. Breakthrough pain is characterized by a sudden onset and rapid increase in the pain level and should be treated with correspondingly rapidly effective opioids. The pharmacological characteristics of previously available and routinely prescribed non-retarded opioids do not always correspond in oral galenics to the demands resulting from the definition of tumor breakthrough pain. As alternatives to these substances five different rapidly effective fentanyl preparations are now available for transmucosal administration.     

Ketamine in perioperative analgesia for knee surgeries: Review of evidence from randomized controlled trials

Successful perioperative analgesia for knee surgeries results in improved patient satisfaction and promotes successful rehabilitation. However, effective perioperative pain control is commonly a challenging task for knee surgeries. Such surgical procedures as total knee replacement or knee arthroscopy may be accompanied by severe postoperative pain. As opioids and nonsteroidal anti-inflammatory drugs are commonly used, the side effects of these types of medicines are quite common as well, especially in patients with chronic pain, as they are commonly dissatisfied with regular analgesia. Patients with chronic pain tend to have lower tolerance to pain, and be dependent and tolerant to opioids. These patients typically require higher doses of analgesics, which further negatively affect patients’ safety and the overall perioperative experience. Multimodal perioperative analgesia helps to spare opioids and promote successful rehabilitation. Ketamine is a noncompetitive N-Methyl-d-aspartate (NMDA) receptor antagonist that has been used for multimodal perioperative analgesia as an adjunct to opioids and nonsteroidal anti-inflammatory drugs. Despite the significant number of papers evaluating the role of ketamine in perioperative analgesia, the feasibility of ketamine for perioperative pain control in knee surgeries remains a subject of debate. There are only a limited number of high-quality studies on the topic. We used a systematic approach to evaluate randomized controlled trials with perioperative ketamine used for knee surgeries. The majority of the studies confirmed that the utilization of ketamine in perioperative analgesia was associated with lower pain scores, reduced opioid use, improved knee joint mobility, and an increase in patient tolerance for physical therapy and rehabilitation. The techniques for ketamine administration and dosing varied significantly, which may explain the inconsistencies between the reports. In addition, some of the studies, even those of high quality, used nitrous oxide in both the study and control groups. Nitrous oxide has NMDA receptor antagonist properties, as does ketamine. None of the studies reported whether patients were taking methadone, dextromethorphan, memantine, or magnesium sulfate, which are NMDA receptor antagonists too. The concomitant use of NMDA receptor antagonists, other than ketamine, may have interfered with the realization of analgesic effects of ketamine. Although it is largely accepted that NMDA receptor antagonism at the spinal level explains most of the analgesic effects of ketamine, it also interacts at other multiple receptors centrally, including, cholinergic receptors, nicotinic and muscarinic, adrenergic, central NMDA, and non-NMDA glutamate receptors. These influences may potentially explain why patients treated with other NMDA receptor antagonists had improved with ketamine as well. Ketamine also interacts with opioid receptors at supraspinal sites, where it produces supraspinal antinociception. Some of the studies did not report whether the participants were opioid naïve or opioid dependent. That might be an important determinant of the analgesic effect because opioid dependent patients are shown to benefit from the ketamine significantly. None of the examined randomized controlled trials assessed the effects of ketamine on opioid dependent patients. The variability between the outcomes of ketamine utilization for perioperative analgesia for knee surgeries might be, at least partially, explained by these findings.     

阿片类药物依赖患者的术后镇痛

背景 阿片类药物是术后镇痛的主要药物,但长期使用阿片类药物的患者因对阿片类药物产生耐受而难以得到较理想的临床术后镇痛效果.目的 讨论如何采用不同的镇痛技术和药物来更好地为这些患者提供良好镇痛.内容 介绍阿片类药物依赖的流行病学及术后镇痛特点,如何对阿片类药物依赖规范合理使用阿片类药物及辅助类镇痛药物,麻醉医生擅长的神经...     

阿片类药物依赖患者的术后镇痛

背景 阿片类药物是术后镇痛的主要药物,但长期使用阿片类药物的患者因对阿片类药物产生耐受而难以得到较理想的临床术后镇痛效果.目的 讨论如何采用不同的镇痛技术和药物来更好地为这些患者提供良好镇痛.内容 介绍阿片类药物依赖的流行病学及术后镇痛特点,如何对阿片类药物依赖规范合理使用阿片类药物及辅助类镇痛药物,麻醉医生擅长的神经阻滞技术在该类患者应有独特的地位.趋向 在阿片类药物依赖患者,通过使用阿片类药物、局麻药和辅助性镇痛药,将不同作用机制的药物或方法联合使用,发挥药物的相加或协同作用的平衡镇痛及多模式镇痛将是术后镇痛技术的主要发展方向.     

Techniques of opioid administration

Opioids continue to be the main pharmacological treatment for severe acute pain. Traditional methods of opioid administration (oral, intramuscular, subcutaneous) are more effective in managing pain if the treatment regimens are individualized and dosages are titrated to effect (pain relief). Oxycodone, an opioid agonist similar in potency to morphine, has proved useful as an oral step-down analgesic in the treatment of acute postoperative pain for a number of surgical procedures (orthopaedic, abdominal, gynaecological). It is also a valuable alternative opioid to morphine intravenous patient-controlled analgesia (IV PCA) in those patients who experience severe unpleasant side effects, such as nausea and hallucinations. Other PCA modalities available for opioid administration in the treatment of acute pain include epidural and transmucosal (intranasal, sublingual, buccal). Transdermal delivery of highly lipid-soluble opioids is available for the treatment of severe pain in chronic and palliative care. This passive drug delivery system is not suitable for the routine management of severe acute pain because rapid and reliable changes to the delivery rate are not possible. However, advances in transdermal delivery system technology have led to the development of a non-invasive PCA system for the management of acute postoperative pain, which utilizes the process of iontophoresis. The fentanyl HCI iontophoretic transdermal system (fentanyl ITS) has the potential to be a valuable modality in the future management of acute postoperative pain.     

Systemic analgesia: an update

Postoperative pain is now a critical focus of perioperative patient care. The current perioperative analgesic strategy is a "balanced-multimodal analgesia". Cornerstones of this treatment approach are patient controlled neuraxial administration of local anesthetics and opioids or patient controlled intravenous administration of opioids. However, systemic opioids are limited by side effects. Thus, adjuvants like anticonvulsants, NMDA receptor antagonists, alpha-2 adrenergic agonists and other non-Opioid analgesics are considered to reduce pain and opioid requirements in the perioperative period. In the present review we discuss recent findings about the effectiveness of different systemic administered adjuvants including ketamine, lidocaine, gabapentin, pregabalin and corticosteroids for postoperative pain treatment. Furthermore a nurse based oral analgesic concept using controlled released Oxycodon for all postoperative patients without a patient controlled analgesia device will be introduced.     

Postoperative Pain Management in Total Knee Arthroplasty

Total knee arthroplasty (TKA) is one of the most common surgeries performed to relieve joint pain in patients with end‐stage osteoarthritis or rheumatic arthritis of the knee. However, TKA is followed by moderate to severe postoperative pain that affects postoperative rehabilitation, patient satisfaction, and overall outcomes. Historically, opioids have been widely used for perioperative pain management of TKA. However, opioids are associated with undesirable adverse effects, such as nausea, respiratory depression, and retention of urine, which limit their application in daily clinical practice. The aim of this review was to discuss the current postoperative pain management regimens for TKA. Our review of the literature demonstrated that multimodal analgesia is considered the optimal regimen for perioperative pain management of TKA and improves clinical outcomes and patient satisfaction, through a combination of several types of medications and delivery routes, including preemptive analgesia, neuraxial anesthesia, peripheral nerve blockade, patient‐controlled analgesia and local infiltration analgesia, and oral opioid/nonopioid medications. Multimodal analgesia provides superior pain relief, promotes recovery of the knee, and reduces opioid consumption and related adverse effects in patients undergoing TKA.