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Perioperative Analgesic Approach to Patients on Baseline Opioid … 451
Opioid overdose rates are higher in men than in women, although women aged
40–64 are the demographic showing the fastest growth rates in overdoses and emer-
gency room visits, and death rates are increasing for people of all ages [6]. Non-
Hispanic whites represent the racial group associated with the highest overdose risk
[7]. Historically, the population hardest hit by the opioid crisis has been white Amer-
icans without college degrees from rural areas that have experienced declines in
manufacturing and construction jobs [8]. The higher rates in white, non-Hispanic
populations has been attributed to bias from providers being less likely to prescribe
opioids to non-whites, but the rate of overdose in black populations has been rising
as the epidemic shifts from largely prescription opioids to fentanyl and heroin [9].
Additionally, there exists a relationship between mental health disorders and
substance abuse. People with anxiety and depression are three times more likely
to abuse opioids [10]. In addition to mental health disorders, those with physical
ailments are also disproportionately affected by opioid misuse. Examples include
those with chronic pain or patients with back or knee pain requiring surgical
intervention [11, 12].
Alcoholism is another indication for opioid antagonists and mixed opioid antag-
onists/agonist treatment. Alcohol abuse is most prevalent in men and whites when
compared to blacks, Asians, and Hispanics. It is also more common in those who are
unmarried and of lower socioeconomic status [13]. The prevalence of alcohol abuse
generally decreases with age, with the highest incidence in those aged 20–29 and
generally decreasing with age [14].
Although drug addiction is a large societal problem, only one in six individuals
struggling with substance use disorders seeks treatment [15]. The least likely popula-
tions to seek treatment for substance use disorders include traditionally underserved
groups including the elderly, racial-ethnic minorities, low-income individuals, the
un-insured, and people living in rural populations [16]. Therefore, those most likely
to be receiving treatment include those with historically better access to healthcare.
3 Implications for the Perioperative Setting
There are many challenges that may be encountered when treating patients prescribed
opioid antagonists or mixed agonist/antagonists in the perioperative setting. These
include patient concerns and fears of experiencing both pain and bias in the perioper-
ative period as well as the clinical challenges in treating pain. Patients might also be
concerned about what analgesic options might be available and how well they will
work given the medications they are taking. The following content will discuss preop-
erative, intraoperative, and postoperative considerations for those patients exposed
to baseline opioid antagonists and mixed opioid antagonist/agonist treatment.
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452 A. Heyer et al.
4 Preoperative Management
Patients with SUDs often experience significant anxiety surrounding surgery. Fears
about stigma and shame about their condition can limit what patients choose to
disclose about their medical background, opioid administration history,and struggles
with substance use disorders [17]. Patients may also worry about receiving adequate
pain relief, experiencing withdrawal symptoms, and relapsing [17]. It is important to
keep these worries in mind when treating this population and approach these patients
in a non-judgmental fashion.
For preoperative planning, it is important to contact the healthcare professional
managing the patient’s opioid receptor modulation prescriptions. It is also worth
considering a multi-specialty consult that includes the surgical team, acute pain,
chronic pain and/or addiction pain medicine services [17]. Involving the patient’s
baseline opioid receptor modulator prescribers and securing patient buy-in while
simultaneously addressing education and patient-specific goals and concerns is
an imperative component of successful analgesic planning paradigms. The risks
of relapse should be discussed with patients and they should be provided with
concerning signs and symptoms that might trigger further evaluation. Table 1
provides an outline of opioid receptor modulators and considerations for use in the
perioperative period.
Table 1 Summary of opioid receptor modulators with agonist or partial agonist actions [18–21,
21–31]
Buprenorphineand
buprenorphine-naloxone
Naltrexone
Mechanism of action Partial agonist at mu receptor,
can be combined with
naloxonewhich acts as an
antagonist at the mu receptor
Full antagonist at mu receptor
Common dosages 2–24 mg with SL or PO daily
(for OUD); mcg dosing for
chronic pain
PO daily: 50 mg
IM depot injection: 380 mg (q
21 days)
Pre-op recommendations Continue the patient’s home
dose during the perioperative
period
PO: Hold for 72 hours prior to
surgery
IM: Hold 4 weeks after last
injection
Post- op recommendations Consider splitting daily home
dose into BID or TID for
improved analgesiafor acute
pain
Patients should be monitored
carefully for signs and symptoms
of inappropriate opioidtherapy
For both buprenorphineand naltrexone, it is important to communicate with the patient’s MOUD
outpatient prescriber to coordinate preoperative and postoperative discharge planning
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Perioperative Analgesic Approach to Patients on Baseline Opioid … 453
Mixed Agonist/Antagonist and Partial Agonist Therapies
The most commonly prescribed agent utilized as an opioid abuse abatement tool is
buprenorphine which is a partial mu-opioid receptor agonist and an antagonist at the
kappa-opioid receptor. Many healthcare professionals experience trepidation when
treating acute postoperative pain in patients prescribed buprenorphine secondary to
its long half-life, high affinity for the mu opioid receptor and its ability to displace
full mu receptor agonists. Although there are many misconceptions surrounding
buprenorphine and its impact on perioperative analgesia, it is important to recall that
buprenorphine has potent analgesic properties related to its high affinity for binding
to mu opioid receptors. Even with its high binding affinity, at standard dosing of
buprenorphine, there remain open receptors available for binding of full mu receptor
agonists and therefore it may still be advisable to consider the administration of
full opioid receptor agonists. Alternatively, harnessing buprenorphine’s analgesic
properties through dose escalation or divided dosing may accomplish significant
analgesic provision without significantly increasing the risk of respiratory depression
or euphoric effects seen with shorter acting mu agonists. [18].
When used for opioid use disorder, buprenorphine can be combined with naloxone
(Suboxone) in an abuse deterrent formulation. When left untampered, the naloxone
contained within Suboxone is inactive and does not hinder opioid activity at mu recep-
tors. In the event of attempted pharmacologic tampering, the naloxone in suboxone
is activated thereby prompting mu receptor antagonism and opioid withdrawal. This
class of drugs is indicated in the treatment of both chronic pain and OUD, but the
formulations and dosages differ. The indication for OUD is dosed in milligrams,
while microgram dosing is used for chronic pain [18].
The perioperative management of patients prescribed buprenorphine has evolved
substantially over time as experience with the drug accumulates and further studies
have been published. It was previously recommended that buprenorphine be discon-
tinued prior to surgery to increase opioid receptor availability. However, this prac-
tice was concerning because of the potential for abuse in patients with a history
of substance abuse disorder or medication management challenges in patients who
required re-initiation of buprenorphine treatment. Consensus opinion now recom-
mends continuing buprenorphine throughout the perioperative period. According to
their 2020 updates on national practice guidelines for the treatment of opioid use
disorder, the American Society of Addiction Medicine states that “discontinuation
of methadone or buprenorphine before surgery is not required. Higher potency
intravenous full agonist opioids can be used perioperatively for analgesia” [19].
Furthermore, a clinical practice advisory reports that it is rarely recommended
to wean or decrease the patient’s home dose [20]. As always, these considerations
need to be tailored to the individual patient and the resources available at an indi-
vidual institution. It is important to have adequate preoperative planning with patients
on buprenorphine including communication with their prescriber and discussion
with the patient. Utilization of multimodal analgesic and regional anesthesia, when
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454 A. Heyer et al.
possible, should be considered, in addition to consulting with an acute pain service,
depending on location resources.
For patients maintained on buprenorphine-naloxone treatment, the current
consensus is to continue treatment; however, discontinuing buprenorphine-naloxone
2–5 days prior to elective surgery has been reported [21, 22]. If a patient has been off
buprenorphine-naloxone for greater than 5 days, the patient can be treated with full
mu receptor agonist opioids. However, if it was not discontinued, it is important to
consider the level of pain associated with the procedure. If there is minimal antici-
pated postoperative pain, it is appropriate to proceed with the surgery. If moderate to
severe pain is anticipated, some protocols suggest canceling the surgery if possible
and contacting the patient’s buprenorphine-naloxone provider to plan for discontin-
uing the patient’s medication at least 5 days prior to the procedure and transitioning
to short acting opioids. However, some protocols suggest holding buprenorphine-
naloxone on the day of surgery and others suggest continuing it, so the patient’s
goals will have to be kept in mind [22–24]. However, the risk of relapse in patients
maintained on suboxone is now generally seen as a contraindication t o pausing
therapy in most patients presenting for surgery.
There are advantages to continuing buprenorphine or buprenorphine-naloxone in
the perioperative period that should be considered prior to making medication admin-
istration recommendations. Short acting opioids in the absence of opioid receptor
antagonism may not the best choice for treating postoperative pain in patients with a
history of opioid use disorder as these patients may be susceptible to their euphoria-
inducing properties. This property exposes these patients to an elevated risk of relapse
during a period when they may already be anxious and vulnerable. Another advantage
to continuing preoperative buprenorphine or suboxone regimens is through the main-
tenance of stable levels of these therapeutics throughout the perioperative period and
a diminished need to make outpatient follow-up dosing adjustments [25–27]. Lastly,
some case reports have shown that there is no benefit to discontinuing these drugs
before surgery and therefore pausing therapy may be exposing patients to an elevated
risk profile without an accompanying benefit [28–30]. The risk of relapse with peri-
operative buprenorphine or suboxone discontinuation is real and one study reported
a > 50% chance of recurrence of OUD when buprenorphine was discontinued [32].
Given the evidence that patients’ pain can be treated effectively without pausing
buprenorphine or buprenorphine-naloxone, it can be advantageous for patients to
continue use throughout the perioperative period to reduce their risk of relapse.
Naltrexone
Naltrexone is a full antagonist at the mu-opioid receptor that causes exogenous opioid
administration to be ineffective. In addition to the treatment of opioid use disor-
ders, naltrexone is also used in the treatment of alcohol use disorder. Naltrexone
is administered as a monthly injectable formulation and an oral formulation. The
oral formulation is dosed daily, whereas the longer acting injectable is usually dosed
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Perioperative Analgesic Approach to Patients on Baseline Opioid … 455
every 21 days. Unlike buprenorphine which is recommended to be continued in the
perioperative period, naltrexone will need to be held for surgeries where perioper-
ative opioids will be required. The recommendations on holding naltrexone differ
depending on the formulation, but careful planning should include communication
with the patient’s naltrexone prescriber to ensure adequate analgesia planning. For
those maintained on the oral formulation, a wash-out period of at least 72 hours is
necessary prior to proceeding with elective surgery. If a patient is maintained on
the injectable formulation, elective surgery should be scheduled at least 4 weeks
following the last dose. Again, planning should involve the patient’s naltrexone
prescriber, and concerns for pain management as well as relapse should be discussed.
If the patient has any previous experience with surgery and challenging postoperative
analgesia, these concerns should be discussed in advance of surgery to allow for the
creation of a shared perioperative analgesic management plan [21, 31].
5 Postoperative Management
In all patients with a history of opioid use disorder, it is important to maximize
multimodal analgesic therapies. If buprenorphine-naloxone or buprenorphine has
been discontinued, a substance abuse or addiction medicine consult is advisable
to provide guidance on follow-up and eventual resumption of Suboxone dosing.
[21]. Acetaminophen, gabapentin/pregabalin, NSAIDs, ketamine/lidocaine infu-
sions, and alpha-2 agonists (dexmedetomidine) should be considered as agents that
might decrease pain in the setting of opioid receptor occupation/antagonism. Non-
pharmacologic analgesic approaches including acupuncture, behavioral therapy,
massage, etc. may be useful approaches in these patients less likely to respond to
opioid analgesics [21]. Long-acting opioids including methadone should be consid-
ered as a mechanism for providing consistent opioid receptor action and short acting
intravenous opioids, often in the form of a PCA, should be offered for severe break-
through pain. Regional anesthesia techniques should be maximized to the extent
possible and the use of catheter techniques or local anesthetic additives may be more
beneficial in these patients less likely to respond to opioid analgesics [21, 33]. The
dose of buprenorphine-naloxone or buprenorphine should be divided into 3–4 times
per day for better coverage [21]. Finally, patients should be closely monitored after
surgery for any signs of cravings or withdrawal, and the patient’s emotional state and
level of anxiety should be frequently assessed. It is important to ensure that patients
feel safe and that their analgesic needs are appropriately addressed. If opioids are
needed postoperatively, it is important to ensure that they are stored and administered
safely to reduce the risk of misuse, relapse and overdose [21].
With long-term naltrexone use, there is a resulting increase in the density of opioid
receptors. If naltrexone is not held prior to a surgical procedure, it is important to
keep in mind that higher than expected opioid dosing will be required to accomplish
targeted analgesic goals [34]. If naltrexone is held, opioid administration will result
in a greater than expected clinical effect secondary to receptor upregulation [35].
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456 A. Heyer et al.
This scenario may be challenging because a proportional increase in the patient’s
sensitivity to opioids may increase the risk of overdose and significant sedation and
respiratory depression [36]. It is therefore important to monitor these patients closely
for any signs of excessive opioid administration [21]. Multimodal approaches to pain
control represents a sound analgesic strategy and regional anesthesia techniques may
be of particular benefit in the setting of emergency surgery when there is inadequate
time for medication management or optimization [21].
6 Discharge Planning
For patients on both naltrexone, buprenorphine, and buprenorphine-naloxone, it is
imperative that good follow-up be arranged with the patient’s primary care provider
and analgesic prescriber. Any pain medications continued postoperatively and at
discharge will need to be accompanied by very clear dosing and monitoring instruc-
tions. Coordination with the patient’s medication prescriber will help ensure that
chronic pain or abuse deterrent medications are continued appropriately or restarted in
a timely manner [21]. Finally, patient education that focuses on the risks of overdose
and a prescription for naloxone should be strongly considered [21].
Key Points
•
Buprenorphine alone or combined with naloxone can be continued throughout
the perioperative setting to reduce the risk of relapse.
•
If buprenorphine, alone or combined with naloxone, is discontinued prior to
surgery, treatment with standard opioid dosing regimens is generally appropriate.
•
Regardless of whether buprenorphine or buprenorphine-naloxone is continued
into the perioperative period or not, it is important to maximize multimodal pain
regimens including acetaminophen, gabapentin, and NSAIDS. Ketamine or alpha-
2 agonist infusions/transdermal administration can be considered as analgesic
adjuncts or in patients with contraindications to regional anesthetic techniques.
•
The dose of buprenorphine and buprenorphine-naloxone should be divided up
into 3–4 times per day.
•
Naltrexone has a monthly injectable formulation and an oral formulation. For
those maintained on the oral formulation, a wash-out period of at l east 72 hours is
necessary prior to proceeding with elective surgery. If a patient is on the injectable
formulation, elective surgery should be scheduled at least 4 weeks after the last
dose.
•
If naltrexone was not held, it is important to keep in mind that higher than expected
amounts of opioids will need to be used.
•
If naltrexone was held, any opioids given will cause a greater than expected effect
due to the upregulation of receptors. It is therefore very important to monitor these
patients closely for any sign of overdose.
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Perioperative Analgesic Approach to Patients on Baseline Opioid … 457
•
For patients on naltrexone, buprenorphine, and buprenorphine-naloxone, it is
imperative that patients be followed closely by their primary care and mainte-
nance regimen prescribers. Excess opioid/overdose monitoring education and a
naloxone prescription offer a degree of safety in patients at elevated risk for
opioid-related sedation and respiratory depression.
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Interventions
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Chronic Pain Procedures in Anticipation
of Surgery/Pain Status Optimization
Loren Shamalov, Yehuda Masturov, and Gary S. Schwartz
Abstract This chapter addresses the issue of chronic pain in anticipation of surgery
and the importance of a multidisciplinary approach for pain status optimization. It
provides insights into the classification of chronic pain, emphasizing neuropathic and
nociceptive pain. Preoperative assessment and evaluation methods, including pain
assessment tools and diagnostic tests, are discussed to aid in devising individual-
ized pain management plans. Non-pharmacological interventions, such as physical
therapy and rehabilitation, are explored as effective approaches to managing chronic
pain. The chapter further discusses the preoperative use of interventional pain proce-
dures, such as peripheral nerve stimulation, epidural steroid injections, and facet joint
injections, highlighting their benefits and limitations. Preoperative pain optimization
strategies, with a focus on timing interventions and procedures, are also discussed
to improve surgical outcomes and reduce postoperative complications.
Keywords Chronic pain
· Preoperative pain · Surgical outcomes · Pain
management
· Interventional pain procedures · Epidural steroid injections ·
Peripheral nerve stimulation · Facet joint injections · Multidisciplinary approach
L. Shamalov · Y. Masturov
CUNY School of Medicine, New York, NY, USA
e-mail: ymastur000@citymail.cuny.edu
G. S. Schwartz (
B
)
Maimonides Medical Center, 4802 tenth ave, Brooklyn, NY, USA
e-mail: Gschwartz@maimo.org; Gary.Schwartz@AABPCorp.com
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Abd-Elsayed and K. Schroeder (eds.), Perioperative Pain Management,
https://doi.org/10.1007/978-3-031-67648-2_29
461
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