Opioid use disorder - Revision history

Bsumida1 at 19:25, 20 June 2025

2025-06-20T19:25:43Z

← Older revision		Revision as of 12:25, 20 June 2025
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	== Anesthetic implications ==		== Anesthetic implications ==
	Patients with opioid use disorder on maintenance therapy with Suboxone (buprenorphine-naloxone) or methadone are at high risk of inadequately controlled pain post-procedure due to low dosing or slow titration. Additionally, patients with poorly managed pain are at risk of prolonged hospital stays, increased cravings, and potential relapse<ref>{{Cite web\|url=https://pubs.asahq.org/anesthesiology/article/126/6/1180/18722/To-Stop-or-Not-That-Is-the-QuestionAcute-Pain\|access-date=2022-08-03\|website=pubs.asahq.org}}</ref>.		Patients with opioid use disorder on maintenance therapy with Suboxone (buprenorphine-naloxone) or methadone are at high risk of inadequately controlled pain post-procedure due to low dosing or slow titration. Additionally, patients with poorly managed pain are at risk of prolonged hospital stays, increased cravings, and potential relapse when maintenance therapy is held and then restarted post-operatively<ref>{{Cite web\|url=https://pubs.asahq.org/anesthesiology/article/126/6/1180/18722/To-Stop-or-Not-That-Is-the-QuestionAcute-Pain\|access-date=2022-08-03\|website=pubs.asahq.org}}</ref>.

	== Pathophysiology ==		== Pathophysiology ==
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	=== Preoperative optimization ===		=== Preoperative optimization ===
	Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal\|last=Alford\|first=Daniel P.\|last2=Compton\|first2=Peggy\|last3=Samet\|first3=Jeffrey H.\|date=2006-01-17\|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy\|url=https://pubmed.ncbi.nlm.nih.gov/16418412/\|journal=Annals of Internal Medicine\|volume=144\|issue=2\|pages=127–134\|doi=10.7326/0003-4819-144-2-200601170-00010\|issn=1539-3704\|pmc=1892816\|pmid=16418412}}</ref>. This includes Suboxone/buprenorphine with the caveat that higher doses will ~~outcompete~~ typical full mu-opioid agonists (e.g. fentanyl, hydromorphone). Steps can be taken to optimize post-operative pain management prior to surgery. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery to prevent decreased efficacy of full mu-opioid receptor agonists during the treatment of acute pain<ref>{{Cite web\|title=UCSF Guideline for the Perioperative Management of Buprenorphine\|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf\|url-status=live}}</ref><ref>{{Cite journal\|last=Quaye\|first=Aurora Naa-Afoley\|last2=Zhang\|first2=Yi\|date=2018-11-30\|title=Perioperative Management of Buprenorphine: Solving the Conundrum\|url=http://dx.doi.org/10.1093/pm/pny217\|journal=Pain Medicine\|volume=20\|issue=7\|pages=1395–1408\|doi=10.1093/pm/pny217\|issn=1526-2375}}</ref>At doses lower than 8 mg/day of buprenorphine, patients can continue their normal Suboxone dose through procedure day and day of discharge.		Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal\|last=Alford\|first=Daniel P.\|last2=Compton\|first2=Peggy\|last3=Samet\|first3=Jeffrey H.\|date=2006-01-17\|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy\|url=https://pubmed.ncbi.nlm.nih.gov/16418412/\|journal=Annals of Internal Medicine\|volume=144\|issue=2\|pages=127–134\|doi=10.7326/0003-4819-144-2-200601170-00010\|issn=1539-3704\|pmc=1892816\|pmid=16418412}}</ref>. This includes Suboxone/buprenorphine with the caveat that higher doses will out-compete typical full mu-opioid agonists (e.g. fentanyl, hydromorphone). Steps can be taken to optimize post-operative pain management prior to surgery. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery to prevent decreased efficacy of full mu-opioid receptor agonists during the treatment of acute pain<ref>{{Cite web\|title=UCSF Guideline for the Perioperative Management of Buprenorphine\|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf\|url-status=live}}</ref><ref>{{Cite journal\|last=Quaye\|first=Aurora Naa-Afoley\|last2=Zhang\|first2=Yi\|date=2018-11-30\|title=Perioperative Management of Buprenorphine: Solving the Conundrum\|url=http://dx.doi.org/10.1093/pm/pny217\|journal=Pain Medicine\|volume=20\|issue=7\|pages=1395–1408\|doi=10.1093/pm/pny217\|issn=1526-2375}}</ref>At doses lower than 8 mg/day of buprenorphine, patients can continue their normal Suboxone dose through procedure day and day of discharge.

	Similarly, it is recommended that patients continue their dose of home methadone[https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116]. One approach is to split a patient's total daily dose into three divided doses. This takes into account methadone's biphasic pharmacokinetics (having both alpha and beta elimination). Alpha elimination corresponds to methadone's analgesic duration which approximates to 8 hours. This is in contrast to its beta elimination (preventing withdrawal in patient's on opioid maintenance therapy) which lasts 30-60 hours<ref name=":1">{{Cite journal\|last=Harrison\|first=Thomas Kyle\|last2=Kornfeld\|first2=Howard\|last3=Aggarwal\|first3=Anuj Kailash\|last4=Lembke\|first4=Anna\|date=2018-09-01\|title=Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy\|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(18)30045-4/abstract\|journal=Anesthesiology Clinics\|language=English\|volume=36\|issue=3\|pages=345–359\|doi=10.1016/j.anclin.2018.04.002\|issn=1932-2275\|pmid=30092933}}</ref>.		Similarly, it is recommended that patients continue their dose of home methadone[https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116]. One approach is to split a patient's total daily dose into three divided doses. This takes into account methadone's biphasic pharmacokinetics (having both alpha and beta elimination). Alpha elimination corresponds to methadone's analgesic duration which approximates to 8 hours. This is in contrast to its beta elimination (preventing withdrawal in patient's on opioid maintenance therapy) which lasts 30-60 hours<ref name=":1">{{Cite journal\|last=Harrison\|first=Thomas Kyle\|last2=Kornfeld\|first2=Howard\|last3=Aggarwal\|first3=Anuj Kailash\|last4=Lembke\|first4=Anna\|date=2018-09-01\|title=Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy\|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(18)30045-4/abstract\|journal=Anesthesiology Clinics\|language=English\|volume=36\|issue=3\|pages=345–359\|doi=10.1016/j.anclin.2018.04.002\|issn=1932-2275\|pmid=30092933}}</ref>.

Bsumida1 at 02:12, 2 May 2025

2025-05-02T02:12:21Z

← Older revision		Revision as of 19:12, 1 May 2025
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	\| signs_symptoms = Opioid withdrawal may include increased pain, cramping, diarrhea, anxiety, and insomnia.		\| signs_symptoms = Opioid withdrawal may include increased pain, cramping, diarrhea, anxiety, and insomnia.
	\| diagnosis = Consider Clinical Opioid Withdrawal Scoring (COWS)		\| diagnosis = Consider Clinical Opioid Withdrawal Scoring (COWS)
	\| treatment = Consider reinitiating home therapy if ~~not already started~~. Use non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonists (e.g. fentanyl, hydromorphone)		\| treatment = If able, optimize patients' home regimens prior to elective procedures. Consider reinitiating home therapy if stopped. When in doubt, seek guidance from consultants (APS, addiction medicine). Use non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonists (e.g. fentanyl, hydromorphone)
	\| image =		\| image =
	\| caption =		\| caption =
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	== Pathophysiology ==		== Pathophysiology ==
	Buprenorphine is a partial mu-opioid receptor agonist and kappa-opioid receptor. It is unique in that its action at the mu-opioid receptor can block binding of other opioids.		Buprenorphine is a partial mu-opioid receptor agonist and kappa-opioid receptor. It is unique in that its action at the mu-opioid receptor can block binding of other opioids due to its higher affinity.

	Methadone is a synthetic long-acting mu-opioid agonist that similarly binds and occupies receptor. It is multifaceted in that it is an NMDA antagonist (a pathway implicated in the development of opioid tolerance). This explains the perioperative benefits of methadone and ketamine as opioid sensitizers. Methadone also acts as a serotonin and norepinephrine reuptake inhibitor which improves mood in patients (albeit while increasing the risk of serotonin syndrome)<ref name=":0">{{Cite journal\|last=Murphy\|first=Glenn S.\|last2=Szokol\|first2=Joseph W.\|date=2019-09-01\|title=Intraoperative Methadone in Surgical Patients\|url=http://dx.doi.org/10.1097/aln.0000000000002755\|journal=Anesthesiology\|volume=131\|issue=3\|pages=678–692\|doi=10.1097/aln.0000000000002755\|issn=0003-3022}}</ref>.		Methadone is a synthetic long-acting mu-opioid agonist that similarly binds and occupies receptor. It is multifaceted in that it is an NMDA antagonist (a pathway implicated in the development of opioid tolerance). This explains the perioperative benefits of methadone and ketamine as opioid sensitizers. Methadone also acts as a serotonin and norepinephrine reuptake inhibitor which improves mood in patients (albeit while increasing the risk of serotonin syndrome)<ref name=":0">{{Cite journal\|last=Murphy\|first=Glenn S.\|last2=Szokol\|first2=Joseph W.\|date=2019-09-01\|title=Intraoperative Methadone in Surgical Patients\|url=http://dx.doi.org/10.1097/aln.0000000000002755\|journal=Anesthesiology\|volume=131\|issue=3\|pages=678–692\|doi=10.1097/aln.0000000000002755\|issn=0003-3022}}</ref>.
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	=== Preoperative optimization ===		=== Preoperative optimization ===
	Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal\|last=Alford\|first=Daniel P.\|last2=Compton\|first2=Peggy\|last3=Samet\|first3=Jeffrey H.\|date=2006-01-17\|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy\|url=https://pubmed.ncbi.nlm.nih.gov/16418412/\|journal=Annals of Internal Medicine\|volume=144\|issue=2\|pages=127–134\|doi=10.7326/0003-4819-144-2-200601170-00010\|issn=1539-3704\|pmc=1892816\|pmid=16418412}}</ref>. ~~The dose of~~ buprenorphine ~~has implications for~~ the ~~risk of~~ opioid ~~tolerance and increased~~ post-operative pain. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery to prevent decreased efficacy of full mu-opioid agonists during the treatment of acute pain<ref>{{Cite web\|title=UCSF Guideline for the Perioperative Management of Buprenorphine\|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf\|url-status=live}}</ref><ref>{{Cite journal\|last=Quaye\|first=Aurora Naa-Afoley\|last2=Zhang\|first2=Yi\|date=2018-11-30\|title=Perioperative Management of Buprenorphine: Solving the Conundrum\|url=http://dx.doi.org/10.1093/pm/pny217\|journal=Pain Medicine\|volume=20\|issue=7\|pages=1395–1408\|doi=10.1093/pm/pny217\|issn=1526-2375}}</ref>At doses lower than 8 mg/day of buprenorphine, patients can continue their normal Suboxone dose through procedure day and day of discharge.		Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal\|last=Alford\|first=Daniel P.\|last2=Compton\|first2=Peggy\|last3=Samet\|first3=Jeffrey H.\|date=2006-01-17\|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy\|url=https://pubmed.ncbi.nlm.nih.gov/16418412/\|journal=Annals of Internal Medicine\|volume=144\|issue=2\|pages=127–134\|doi=10.7326/0003-4819-144-2-200601170-00010\|issn=1539-3704\|pmc=1892816\|pmid=16418412}}</ref>. This includes Suboxone/buprenorphine with the caveat that higher doses will outcompete typical full mu-opioid agonists (e.g. fentanyl, hydromorphone). Steps can be taken to optimize post-operative pain management prior to surgery. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery to prevent decreased efficacy of full mu-opioid receptor agonists during the treatment of acute pain<ref>{{Cite web\|title=UCSF Guideline for the Perioperative Management of Buprenorphine\|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf\|url-status=live}}</ref><ref>{{Cite journal\|last=Quaye\|first=Aurora Naa-Afoley\|last2=Zhang\|first2=Yi\|date=2018-11-30\|title=Perioperative Management of Buprenorphine: Solving the Conundrum\|url=http://dx.doi.org/10.1093/pm/pny217\|journal=Pain Medicine\|volume=20\|issue=7\|pages=1395–1408\|doi=10.1093/pm/pny217\|issn=1526-2375}}</ref>At doses lower than 8 mg/day of buprenorphine, patients can continue their normal Suboxone dose through procedure day and day of discharge.

	Similarly, it is recommended that patients continue their dose of home methadone[https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116]. One approach is to split a patient's total daily dose into three divided doses. This takes into account methadone's biphasic pharmacokinetics (having both alpha and beta elimination). Alpha elimination corresponds to methadone's analgesic duration which approximates to 8 hours. This is in contrast to its beta elimination (preventing withdrawal in patient's on opioid maintenance therapy) which lasts 30-60 hours<ref name=":1">{{Cite journal\|last=Harrison\|first=Thomas Kyle\|last2=Kornfeld\|first2=Howard\|last3=Aggarwal\|first3=Anuj Kailash\|last4=Lembke\|first4=Anna\|date=2018-09-01\|title=Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy\|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(18)30045-4/abstract\|journal=Anesthesiology Clinics\|language=English\|volume=36\|issue=3\|pages=345–359\|doi=10.1016/j.anclin.2018.04.002\|issn=1932-2275\|pmid=30092933}}</ref>.		Similarly, it is recommended that patients continue their dose of home methadone[https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116]. One approach is to split a patient's total daily dose into three divided doses. This takes into account methadone's biphasic pharmacokinetics (having both alpha and beta elimination). Alpha elimination corresponds to methadone's analgesic duration which approximates to 8 hours. This is in contrast to its beta elimination (preventing withdrawal in patient's on opioid maintenance therapy) which lasts 30-60 hours<ref name=":1">{{Cite journal\|last=Harrison\|first=Thomas Kyle\|last2=Kornfeld\|first2=Howard\|last3=Aggarwal\|first3=Anuj Kailash\|last4=Lembke\|first4=Anna\|date=2018-09-01\|title=Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy\|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(18)30045-4/abstract\|journal=Anesthesiology Clinics\|language=English\|volume=36\|issue=3\|pages=345–359\|doi=10.1016/j.anclin.2018.04.002\|issn=1932-2275\|pmid=30092933}}</ref>.
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	Similarly, IV methadone given as a single dose of 0.1-0.3 mg/kg (based on ideal body weight) has been reported to significantly reduce post-operative opioid requirements and has been studied extensively in patient's receiving spinal fusion procedures<ref name=":0" />. This has not been studied well however amongst patients already on methadone or those with opioid use disorder. If given intraoperatively, it would be prudent to compare this dosing with the patient's home methadone dose (given TID). Generally, 1/2 to 1/3 of a patient's oral methadone dose is thought to be the equivalent IV dose<ref name=":1" />.		Similarly, IV methadone given as a single dose of 0.1-0.3 mg/kg (based on ideal body weight) has been reported to significantly reduce post-operative opioid requirements and has been studied extensively in patient's receiving spinal fusion procedures<ref name=":0" />. This has not been studied well however amongst patients already on methadone or those with opioid use disorder. If given intraoperatively, it would be prudent to compare this dosing with the patient's home methadone dose (given TID). Generally, 1/2 to 1/3 of a patient's oral methadone dose is thought to be the equivalent IV dose<ref name=":1" />.

	Concurrent use of both Suboxone and methadone is not recommended both perioperatively and as an outpatient due to ~~the opioid antagonist effects of naloxone and~~ shared cytochrome metabolism<ref>{{Cite book\|url=https://www.ncbi.nlm.nih.gov/books/NBK143177/\|title=Drug interactions involving methadone and buprenorphine\|date=2009\|publisher=World Health Organization\|language=en}}</ref>.		Concurrent use of both Suboxone and methadone is not recommended both perioperatively and as an outpatient due to shared cytochrome metabolism<ref>{{Cite book\|url=https://www.ncbi.nlm.nih.gov/books/NBK143177/\|title=Drug interactions involving methadone and buprenorphine\|date=2009\|publisher=World Health Organization\|language=en}}</ref>.

	Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression (seen in older patients, those with OSA, and patients with end-organ failure).		Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression (seen in older patients, those with OSA, and patients with end-organ failure).

	=== Postoperative management ===		=== Postoperative management ===
	Consider continuing patients' Suboxone or methadone while simultaneously implementing a multimodal post-operative pain management plan. Providers should continue typical opioid regimens for mild-severe pain (oxycodone, fentanyl, hydromorphone) ~~acknowledging that~~ higher than normal starting doses of opioids may be required. The typical calculation of milligram morphine equivalents (MME) do not give an accurate sense of equivalent dosing. Regional techniques (neuraxial, peripheral nerve catheters), gabapentinoids, and ketamine can be important supplements to reduce opioid needs. Providers may also consider post-operative stay in the ICU for pain management and consultation of in-house pain service.		Consider continuing patients' Suboxone or methadone while simultaneously implementing a multimodal post-operative pain management plan. If anticipating difficult to control post-operative pain and on high doses of buprenorphine, ''consider'' discontinuing acknowledging pain management may still be difficult and substance abuse relapse is more likely. The risk of respiratory depression will also be increased as buprenorphine is displaced from mu-opioid receptors by full agonists<ref>{{Cite journal\|last=Anderson\|first=T. Anthony\|last2=Quaye\|first2=Aurora N. A.\|last3=Ward\|first3=E. Nalan\|last4=Wilens\|first4=Timothy E.\|last5=Hilliard\|first5=Paul E.\|last6=Brummett\|first6=Chad M.\|date=2017-06\|title=To Stop or Not, That Is the Question: Acute Pain Management for the Patient on Chronic Buprenorphine\|url=https://pmc.ncbi.nlm.nih.gov/articles/PMC7041233/\|journal=Anesthesiology\|volume=126\|issue=6\|pages=1180–1186\|doi=10.1097/ALN.0000000000001633\|issn=1528-1175\|pmc=7041233\|pmid=28511196}}</ref>. Providers should continue typical opioid regimens for mild-severe pain (oxycodone, fentanyl, hydromorphone), however higher than normal starting doses of opioids may be required. The typical calculation of milligram morphine equivalents (MME) do not give an accurate sense of equivalent dosing. Regional techniques (neuraxial, peripheral nerve catheters), gabapentinoids, and ketamine can be important supplements to reduce opioid needs. Providers may also consider post-operative stay in the ICU for pain management and consultation of in-house pain service. When in doubt, utilize acute pain and addiction medicine services, particularly to manage reinitiation of therapy.

	== References ==		== References ==
	[[Category:Comorbidities]]		[[Category:Comorbidities]]

Bsumida1 at 03:50, 22 January 2023

2023-01-22T03:50:40Z

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	{{Infobox comorbidity		{{Infobox comorbidity
	\| anesthetic_relevance = High		\| anesthetic_relevance = High
	\| anesthetic_management = Suboxone/methadone therapy may be continued		\| anesthetic_management = Suboxone or methadone therapy may be continued
	\| specialty = Pain		\| specialty = Pain
	\| signs_symptoms = Opioid withdrawal may include increased pain, cramping, diarrhea, anxiety, and insomnia.		\| signs_symptoms = Opioid withdrawal may include increased pain, cramping, diarrhea, anxiety, and insomnia.

Bsumida1 at 03:50, 22 January 2023

2023-01-22T03:50:13Z

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	{{Infobox comorbidity		{{Infobox comorbidity
	\| anesthetic_relevance = High		\| anesthetic_relevance = High
	\| anesthetic_management = ~~Consider continuing~~ Suboxone/methadone therapy~~. Consider use of non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonist opioid analgesics (e.g. fentanyl, hydromorphone)~~		\| anesthetic_management = Suboxone/methadone therapy may be continued
	\| specialty = Pain		\| specialty = Pain
	\| signs_symptoms = Opioid withdrawal may include increased pain, cramping, diarrhea, anxiety, and insomnia.		\| signs_symptoms = Opioid withdrawal may include increased pain, cramping, diarrhea, anxiety, and insomnia.
			\| diagnosis = Consider Clinical Opioid Withdrawal Scoring (COWS)
			\| treatment = Consider reinitiating home therapy if not already started. Use non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonists (e.g. fentanyl, hydromorphone)
	\| image =		\| image =
	\| caption =		\| caption =

Bsumida1 at 03:45, 22 January 2023

2023-01-22T03:45:47Z

← Older revision		Revision as of 20:45, 21 January 2023
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	{{Infobox comorbidity		{{Infobox comorbidity
	\| anesthetic_relevance = High		\| anesthetic_relevance = High
	\| anesthetic_management = ~~Use~~ non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonist opioid analgesics (e.g. fentanyl, hydromorphone)		\| anesthetic_management = Consider continuing Suboxone/methadone therapy. Consider use of non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonist opioid analgesics (e.g. fentanyl, hydromorphone)
	\| specialty = Pain		\| specialty = Pain
	\| signs_symptoms = ~~N/A~~		\| signs_symptoms = Opioid withdrawal may include increased pain, cramping, diarrhea, anxiety, and insomnia.
	~~\| diagnosis = N/A~~
	~~\| treatment = N/A~~
	\| image =		\| image =
	\| caption =		\| caption =

Bsumida1 at 03:40, 22 January 2023

2023-01-22T03:40:09Z

← Older revision		Revision as of 20:40, 21 January 2023
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	== Anesthetic implications ==		== Anesthetic implications ==
	Patients with opioid use disorder on maintenance therapy with ~~methadone or~~ Suboxone (buprenorphine-naloxone) are at high risk of inadequately controlled pain post-procedure due to low dosing or slow titration. Additionally, patients with poorly managed pain are at risk of prolonged hospital stays, increased cravings, and potential relapse<ref>{{Cite web\|url=https://pubs.asahq.org/anesthesiology/article/126/6/1180/18722/To-Stop-or-Not-That-Is-the-QuestionAcute-Pain\|access-date=2022-08-03\|website=pubs.asahq.org}}</ref>.		Patients with opioid use disorder on maintenance therapy with Suboxone (buprenorphine-naloxone) or methadone are at high risk of inadequately controlled pain post-procedure due to low dosing or slow titration. Additionally, patients with poorly managed pain are at risk of prolonged hospital stays, increased cravings, and potential relapse<ref>{{Cite web\|url=https://pubs.asahq.org/anesthesiology/article/126/6/1180/18722/To-Stop-or-Not-That-Is-the-QuestionAcute-Pain\|access-date=2022-08-03\|website=pubs.asahq.org}}</ref>.

	== Pathophysiology ==		== Pathophysiology ==

Bsumida1 at 03:39, 22 January 2023

2023-01-22T03:39:27Z

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	}}		}}

	This article focuses primarily on management considerations for patients on methadone ~~or Suboxone~~ therapy.		This article focuses primarily on management considerations for patients on Suboxone or methadone therapy.

	== Epidemiology ==		== Epidemiology ==

Bsumida1 at 03:38, 22 January 2023

2023-01-22T03:38:53Z

← Older revision		Revision as of 20:38, 21 January 2023
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	=== Preoperative optimization ===		=== Preoperative optimization ===
	Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal\|last=Alford\|first=Daniel P.\|last2=Compton\|first2=Peggy\|last3=Samet\|first3=Jeffrey H.\|date=2006-01-17\|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy\|url=https://pubmed.ncbi.nlm.nih.gov/16418412/\|journal=Annals of Internal Medicine\|volume=144\|issue=2\|pages=127–134\|doi=10.7326/0003-4819-144-2-200601170-00010\|issn=1539-3704\|pmc=1892816\|pmid=16418412}}</ref>. The dose of buprenorphine has implications for the risk of opioid tolerance and increased post-operative pain. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery to prevent decreased efficacy of full mu-opioid agonists during the treatment of acute pain<ref>{{Cite web\|title=UCSF Guideline for the Perioperative Management of Buprenorphine\|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf\|url-status=live}}</ref><ref>{{Cite journal\|last=Quaye\|first=Aurora Naa-Afoley\|last2=Zhang\|first2=Yi\|date=2018-11-30\|title=Perioperative Management of Buprenorphine: Solving the Conundrum\|url=http://dx.doi.org/10.1093/pm/pny217\|journal=Pain Medicine\|volume=20\|issue=7\|pages=1395–1408\|doi=10.1093/pm/pny217\|issn=1526-2375}}</ref>. At doses lower than 8 mg/day of buprenorphine, patients can continue their normal Suboxone dose through procedure day and day of discharge.		Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal\|last=Alford\|first=Daniel P.\|last2=Compton\|first2=Peggy\|last3=Samet\|first3=Jeffrey H.\|date=2006-01-17\|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy\|url=https://pubmed.ncbi.nlm.nih.gov/16418412/\|journal=Annals of Internal Medicine\|volume=144\|issue=2\|pages=127–134\|doi=10.7326/0003-4819-144-2-200601170-00010\|issn=1539-3704\|pmc=1892816\|pmid=16418412}}</ref>. The dose of buprenorphine has implications for the risk of opioid tolerance and increased post-operative pain. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery to prevent decreased efficacy of full mu-opioid agonists during the treatment of acute pain<ref>{{Cite web\|title=UCSF Guideline for the Perioperative Management of Buprenorphine\|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf\|url-status=live}}</ref><ref>{{Cite journal\|last=Quaye\|first=Aurora Naa-Afoley\|last2=Zhang\|first2=Yi\|date=2018-11-30\|title=Perioperative Management of Buprenorphine: Solving the Conundrum\|url=http://dx.doi.org/10.1093/pm/pny217\|journal=Pain Medicine\|volume=20\|issue=7\|pages=1395–1408\|doi=10.1093/pm/pny217\|issn=1526-2375}}</ref>At doses lower than 8 mg/day of buprenorphine, patients can continue their normal Suboxone dose through procedure day and day of discharge.

	Similarly, it is recommended that patients continue their dose of home methadone[https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116]. One approach is to split a patient's total daily dose into three divided doses. This takes into account methadone's biphasic pharmacokinetics (having both alpha and beta elimination). Alpha elimination corresponds to methadone's analgesic duration which approximates to 8 hours. This is in contrast to its beta elimination (preventing withdrawal in patient's on opioid maintenance therapy) which lasts 30-60 hours<ref>{{Cite journal\|last=Harrison\|first=Thomas Kyle\|last2=Kornfeld\|first2=Howard\|last3=Aggarwal\|first3=Anuj Kailash\|last4=Lembke\|first4=Anna\|date=2018-09-01\|title=Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy\|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(18)30045-4/abstract\|journal=Anesthesiology Clinics\|language=English\|volume=36\|issue=3\|pages=345–359\|doi=10.1016/j.anclin.2018.04.002\|issn=1932-2275\|pmid=30092933}}</ref>.		Similarly, it is recommended that patients continue their dose of home methadone[https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116]. One approach is to split a patient's total daily dose into three divided doses. This takes into account methadone's biphasic pharmacokinetics (having both alpha and beta elimination). Alpha elimination corresponds to methadone's analgesic duration which approximates to 8 hours. This is in contrast to its beta elimination (preventing withdrawal in patient's on opioid maintenance therapy) which lasts 30-60 hours<ref name=":1">{{Cite journal\|last=Harrison\|first=Thomas Kyle\|last2=Kornfeld\|first2=Howard\|last3=Aggarwal\|first3=Anuj Kailash\|last4=Lembke\|first4=Anna\|date=2018-09-01\|title=Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy\|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(18)30045-4/abstract\|journal=Anesthesiology Clinics\|language=English\|volume=36\|issue=3\|pages=345–359\|doi=10.1016/j.anclin.2018.04.002\|issn=1932-2275\|pmid=30092933}}</ref>.

	Non-opioid agents include medications such as Tylenol and the gabapentinoids, gabapentin/pregabalin. A shared neuro-inflammatory and central sensitization process akin to that of neuropathic pain may explain the cross-benefit of gabapentin in patients with opioid-induced hyperalgesia<ref>{{Cite journal\|last=Compton\|first=Peggy\|last2=Kehoe\|first2=Priscilla\|last3=Sinha\|first3=Karabi\|last4=Torrington\|first4=Matt A.\|last5=Ling\|first5=Walter\|date=2010-06-01\|title=Gabapentin improves cold-pressor pain responses in methadone-maintained patients\|url=https://pubmed.ncbi.nlm.nih.gov/20163921/\|journal=Drug and Alcohol Dependence\|volume=109\|issue=1-3\|pages=213–219\|doi=10.1016/j.drugalcdep.2010.01.006\|issn=1879-0046\|pmc=2875370\|pmid=20163921}}</ref>.		Non-opioid agents include medications such as Tylenol and the gabapentinoids, gabapentin/pregabalin. A shared neuro-inflammatory and central sensitization process akin to that of neuropathic pain may explain the cross-benefit of gabapentin in patients with opioid-induced hyperalgesia<ref>{{Cite journal\|last=Compton\|first=Peggy\|last2=Kehoe\|first2=Priscilla\|last3=Sinha\|first3=Karabi\|last4=Torrington\|first4=Matt A.\|last5=Ling\|first5=Walter\|date=2010-06-01\|title=Gabapentin improves cold-pressor pain responses in methadone-maintained patients\|url=https://pubmed.ncbi.nlm.nih.gov/20163921/\|journal=Drug and Alcohol Dependence\|volume=109\|issue=1-3\|pages=213–219\|doi=10.1016/j.drugalcdep.2010.01.006\|issn=1879-0046\|pmc=2875370\|pmid=20163921}}</ref>.

	=== Intraoperative management ===		=== Intraoperative management ===
	Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) should be strongly considered in a non-opioid driven anesthetic. Providers should consider Toradol and redosing of Tylenol in longer procedures. Ketamine is a useful adjunct due to its useful effect of increasing opioid sensitivity when run at low dose rates (0.2-0.3 mg/kg/hr). ~~It's~~ use may be limited in elderly patients who are at increased risk of experiencing dysphoria/delirium post-operatively or are more sensitive to adverse effects from polypharmacy.		Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) should be strongly considered in a non-opioid driven anesthetic. Providers should consider Toradol and redosing of Tylenol in longer procedures. Ketamine is a useful adjunct due to its useful effect of increasing opioid sensitivity when run at low dose rates (0.2-0.3 mg/kg/hr). Its use may be limited in elderly patients who are at increased risk of experiencing dysphoria/delirium post-operatively or are more sensitive to adverse effects from polypharmacy.

	Similarly, methadone given as a single dose of 0.1-0.3 mg/kg (based on ideal body weight) has been reported to significantly reduce post-operative opioid requirements and has been studied extensively in patient's receiving spinal fusion procedures<ref name=":0" />. This has not been studied well however amongst ~~patient's~~ already on methadone/with ~~history of substance~~ use disorder. ~~It may~~ be ~~worth considering~~		Similarly, IV methadone given as a single dose of 0.1-0.3 mg/kg (based on ideal body weight) has been reported to significantly reduce post-operative opioid requirements and has been studied extensively in patient's receiving spinal fusion procedures<ref name=":0" />. This has not been studied well however amongst patients already on methadone or those with opioid use disorder. If given intraoperatively, it would be prudent to compare this dosing with the patient's home methadone dose (given TID). Generally, 1/2 to 1/3 of a patient's oral methadone dose is thought to be the equivalent IV dose<ref name=":1" />.

	Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression seen older patients, those with OSA, and patients with end-organ failure.		Concurrent use of both Suboxone and methadone is not recommended both perioperatively and as an outpatient due to the opioid antagonist effects of naloxone and shared cytochrome metabolism<ref>{{Cite book\|url=https://www.ncbi.nlm.nih.gov/books/NBK143177/\|title=Drug interactions involving methadone and buprenorphine\|date=2009\|publisher=World Health Organization\|language=en}}</ref>.

			Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression (seen in older patients, those with OSA, and patients with end-organ failure).

	=== Postoperative management ===		=== Postoperative management ===
	Consider continuing methadone ~~and buprenorphine as part of the~~ post-operative pain management plan. ~~Buprenorphine is unlikely to cause respiratory depression and causes less drug euphoria. Naloxone should not be co-administered due to the risk of causing acute withdrawal.~~		Consider continuing patients' Suboxone or methadone while simultaneously implementing a multimodal post-operative pain management plan. Providers should continue typical opioid regimens for mild-severe pain (oxycodone, fentanyl, hydromorphone) acknowledging that higher than normal starting doses of opioids may be required. The typical calculation of milligram morphine equivalents (MME) do not give an accurate sense of equivalent dosing. Regional techniques (neuraxial, peripheral nerve catheters), gabapentinoids, and ketamine can be important supplements to reduce opioid needs. Providers may also consider post-operative stay in the ICU for pain management and consultation of in-house pain service.

	Providers should continue typical regimens for mild-severe pain ~~post-op~~ (oxycodone, fentanyl, hydromorphone)~~, however~~ higher than normal starting doses of opioids may be required. The typical calculation of milligram morphine equivalents (MME) do not give an accurate sense of equivalent dosing.

	~~Consider~~ post-operative stay in the ICU for pain management and consultation of in-house pain service.

	== References ==		== References ==
	[[Category:Comorbidities]]		[[Category:Comorbidities]]

Bsumida1 at 03:05, 22 January 2023

2023-01-22T03:05:41Z

← Older revision		Revision as of 20:05, 21 January 2023
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	== Epidemiology ==		== Epidemiology ==
	According to the 2019 Substance Abuse and Mental Health Administration National Survey on Drug Use and Health, 5.7 million people (2.1 percent of people aged 12 or older) in the US were estimated to have used heroin at some point in their lives while 431,000 (0.2 percent) reported use in the last month~~. Illicit fentanyl and prescription drug misuse have also contributed to rising rates of opioid overdose deaths~~<ref>{{Cite journal\|last=Rudd\|first=Rose A.\|last2=Seth\|first2=Puja\|last3=David\|first3=Felicita\|last4=Scholl\|first4=Lawrence\|date=2016-12-30\|title=Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015\|url=https://pubmed.ncbi.nlm.nih.gov/28033313/\|journal=MMWR. Morbidity and mortality weekly report\|volume=65\|issue=50-51\|pages=1445–1452\|doi=10.15585/mmwr.mm655051e1\|issn=1545-861X\|pmid=28033313}}</ref>.		According to the 2019 Substance Abuse and Mental Health Administration National Survey on Drug Use and Health, 5.7 million people (2.1 percent of people aged 12 or older) in the US were estimated to have used heroin at some point in their lives while 431,000 (0.2 percent) reported use in the last month<ref>{{Cite journal\|last=Rudd\|first=Rose A.\|last2=Seth\|first2=Puja\|last3=David\|first3=Felicita\|last4=Scholl\|first4=Lawrence\|date=2016-12-30\|title=Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015\|url=https://pubmed.ncbi.nlm.nih.gov/28033313/\|journal=MMWR. Morbidity and mortality weekly report\|volume=65\|issue=50-51\|pages=1445–1452\|doi=10.15585/mmwr.mm655051e1\|issn=1545-861X\|pmid=28033313}}</ref>. Illicit fentanyl and prescription drug misuse have also contributed to rising rates of opioid overdose deaths from approximately 3,000 in 2010 to over 15,000 in 2016<ref>{{Cite web\|last=US Department of Justice\|title=2018 National Drug Assessment\|url=https://www.dea.gov/sites/default/files/2018-11/DIR-032-18%202018%20NDTA%20final%20low%20resolution.pdf\|url-status=live\|access-date=January 21, 2023\|website=Drug Enforcement Administration}}</ref>

	== Anesthetic implications ==		== Anesthetic implications ==
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	== Pathophysiology ==		== Pathophysiology ==
	Buprenorphine is a partial mu-opioid receptor agonist and kappa-opioid receptor. It is unique in that its action at the mu-opioid receptor can block binding of other opioids. Methadone is a synthetic long-acting mu-opioid agonist that similarly binds and occupies receptor.		Buprenorphine is a partial mu-opioid receptor agonist and kappa-opioid receptor. It is unique in that its action at the mu-opioid receptor can block binding of other opioids.

			Methadone is a synthetic long-acting mu-opioid agonist that similarly binds and occupies receptor. It is multifaceted in that it is an NMDA antagonist (a pathway implicated in the development of opioid tolerance). This explains the perioperative benefits of methadone and ketamine as opioid sensitizers. Methadone also acts as a serotonin and norepinephrine reuptake inhibitor which improves mood in patients (albeit while increasing the risk of serotonin syndrome)<ref name=":0">{{Cite journal\|last=Murphy\|first=Glenn S.\|last2=Szokol\|first2=Joseph W.\|date=2019-09-01\|title=Intraoperative Methadone in Surgical Patients\|url=http://dx.doi.org/10.1097/aln.0000000000002755\|journal=Anesthesiology\|volume=131\|issue=3\|pages=678–692\|doi=10.1097/aln.0000000000002755\|issn=0003-3022}}</ref>.

	== Anesthetic management ==		== Anesthetic management ==

	=== Preoperative optimization ===		=== Preoperative optimization ===
	Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal\|last=Alford\|first=Daniel P.\|last2=Compton\|first2=Peggy\|last3=Samet\|first3=Jeffrey H.\|date=2006-01-17\|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy\|url=https://pubmed.ncbi.nlm.nih.gov/16418412/\|journal=Annals of Internal Medicine\|volume=144\|issue=2\|pages=127–134\|doi=10.7326/0003-4819-144-2-200601170-00010\|issn=1539-3704\|pmc=1892816\|pmid=16418412}}</ref>. The dose of ~~methadone or~~ buprenorphine has implications for the risk of opioid tolerance and increased post-operative pain. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery<ref>{{Cite web\|title=UCSF Guideline for the Perioperative Management of Buprenorphine\|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf\|url-status=live}}</ref>. At doses lower than 8 mg/day, ~~buprenorphine~~ can ~~be continued~~ through procedure day and day of discharge. Similarly, it is recommended that patients on methadone continue their home dosing peri-operatively[https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116].		Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal\|last=Alford\|first=Daniel P.\|last2=Compton\|first2=Peggy\|last3=Samet\|first3=Jeffrey H.\|date=2006-01-17\|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy\|url=https://pubmed.ncbi.nlm.nih.gov/16418412/\|journal=Annals of Internal Medicine\|volume=144\|issue=2\|pages=127–134\|doi=10.7326/0003-4819-144-2-200601170-00010\|issn=1539-3704\|pmc=1892816\|pmid=16418412}}</ref>. The dose of buprenorphine has implications for the risk of opioid tolerance and increased post-operative pain. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery to prevent decreased efficacy of full mu-opioid agonists during the treatment of acute pain<ref>{{Cite web\|title=UCSF Guideline for the Perioperative Management of Buprenorphine\|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf\|url-status=live}}</ref><ref>{{Cite journal\|last=Quaye\|first=Aurora Naa-Afoley\|last2=Zhang\|first2=Yi\|date=2018-11-30\|title=Perioperative Management of Buprenorphine: Solving the Conundrum\|url=http://dx.doi.org/10.1093/pm/pny217\|journal=Pain Medicine\|volume=20\|issue=7\|pages=1395–1408\|doi=10.1093/pm/pny217\|issn=1526-2375}}</ref>. At doses lower than 8 mg/day of buprenorphine, patients can continue their normal Suboxone dose through procedure day and day of discharge.

	Non-opioid agents such as Tylenol and gabapentin/pregabalin. A shared neuro-inflammatory and central sensitization process akin to that of neuropathic pain may explain the cross-benefit of gabapentin in patients with opioid-induced hyperalgesia<ref>{{Cite journal\|last=Compton\|first=Peggy\|last2=Kehoe\|first2=Priscilla\|last3=Sinha\|first3=Karabi\|last4=Torrington\|first4=Matt A.\|last5=Ling\|first5=Walter\|date=2010-06-01\|title=Gabapentin improves cold-pressor pain responses in methadone-maintained patients\|url=https://pubmed.ncbi.nlm.nih.gov/20163921/\|journal=Drug and Alcohol Dependence\|volume=109\|issue=1-3\|pages=213–219\|doi=10.1016/j.drugalcdep.2010.01.006\|issn=1879-0046\|pmc=2875370\|pmid=20163921}}</ref>.		Similarly, it is recommended that patients continue their dose of home methadone[https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116]. One approach is to split a patient's total daily dose into three divided doses. This takes into account methadone's biphasic pharmacokinetics (having both alpha and beta elimination). Alpha elimination corresponds to methadone's analgesic duration which approximates to 8 hours. This is in contrast to its beta elimination (preventing withdrawal in patient's on opioid maintenance therapy) which lasts 30-60 hours<ref>{{Cite journal\|last=Harrison\|first=Thomas Kyle\|last2=Kornfeld\|first2=Howard\|last3=Aggarwal\|first3=Anuj Kailash\|last4=Lembke\|first4=Anna\|date=2018-09-01\|title=Perioperative Considerations for the Patient with Opioid Use Disorder on Buprenorphine, Methadone, or Naltrexone Maintenance Therapy\|url=https://www.anesthesiology.theclinics.com/article/S1932-2275(18)30045-4/abstract\|journal=Anesthesiology Clinics\|language=English\|volume=36\|issue=3\|pages=345–359\|doi=10.1016/j.anclin.2018.04.002\|issn=1932-2275\|pmid=30092933}}</ref>.

			Non-opioid agents include medications such as Tylenol and the gabapentinoids, gabapentin/pregabalin. A shared neuro-inflammatory and central sensitization process akin to that of neuropathic pain may explain the cross-benefit of gabapentin in patients with opioid-induced hyperalgesia<ref>{{Cite journal\|last=Compton\|first=Peggy\|last2=Kehoe\|first2=Priscilla\|last3=Sinha\|first3=Karabi\|last4=Torrington\|first4=Matt A.\|last5=Ling\|first5=Walter\|date=2010-06-01\|title=Gabapentin improves cold-pressor pain responses in methadone-maintained patients\|url=https://pubmed.ncbi.nlm.nih.gov/20163921/\|journal=Drug and Alcohol Dependence\|volume=109\|issue=1-3\|pages=213–219\|doi=10.1016/j.drugalcdep.2010.01.006\|issn=1879-0046\|pmc=2875370\|pmid=20163921}}</ref>.

	=== Intraoperative management ===		=== Intraoperative management ===
	Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) should be strongly considered in a non-opioid driven anesthetic. Ketamine is a useful adjunct due to its useful effect of increasing opioid sensitivity when run at low dose rates (0.3 mg/kg/hr). ~~Providers should consider Toradol~~ and ~~redosing of Tylenol~~ in ~~longer~~ procedures.		Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) should be strongly considered in a non-opioid driven anesthetic. Providers should consider Toradol and redosing of Tylenol in longer procedures. Ketamine is a useful adjunct due to its useful effect of increasing opioid sensitivity when run at low dose rates (0.2-0.3 mg/kg/hr). It's use may be limited in elderly patients who are at increased risk of experiencing dysphoria/delirium post-operatively or are more sensitive to adverse effects from polypharmacy.

			Similarly, methadone given as a single dose of 0.1-0.3 mg/kg (based on ideal body weight) has been reported to significantly reduce post-operative opioid requirements and has been studied extensively in patient's receiving spinal fusion procedures<ref name=":0" />. This has not been studied well however amongst patient's already on methadone/with history of substance use disorder. It may be worth considering

	Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression seen older patients, those with OSA, and patients with end-organ failure.		Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression seen older patients, those with OSA, and patients with end-organ failure.

Bsumida1 at 12:15, 3 August 2022

2022-08-03T12:15:05Z

← Older revision		Revision as of 05:15, 3 August 2022
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	=== Intraoperative management ===		=== Intraoperative management ===
	Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) ~~are~~ should be strongly considered in a non-opioid driven anesthetic. Ketamine is a useful adjunct due to ~~it's~~ useful effect of increasing opioid sensitivity when run at low dose rates (0.3 mg/kg/hr). Providers should consider Toradol and redosing of Tylenol in longer procedures.		Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) should be strongly considered in a non-opioid driven anesthetic. Ketamine is a useful adjunct due to its useful effect of increasing opioid sensitivity when run at low dose rates (0.3 mg/kg/hr). Providers should consider Toradol and redosing of Tylenol in longer procedures.

	Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression seen older patients, those with OSA, and patients with end-organ failure.		Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression seen older patients, those with OSA, and patients with end-organ failure.