Top

Current Pain and Headache Reports

Published in:

01-06-2020 | Buprenorphine | Other Pain (AD. Kaye and N Vadivelu, Section Editors)

Recommendations for Managing Opioid-Tolerant Surgical Patients within Enhanced Recovery Pathways

Authors: Alexander Stone, Antonia Roberts, Hans D. de Boer, Alan D. Kaye, William J. Fawcett, Richard D. Urman

Published in: Current Pain and Headache Reports | Issue 6/2020

Abstract

Purpose of Review

One of the consequences of the opioid epidemic is an increase in the number of opioid-tolerant patients. These patients are at higher risk for readmission and longer hospital stays following surgery. Enhanced recovery after surgery (ERAS) pathways can be used as a framework for providing high-quality comprehensive care to patient population. It is estimated that as many as 15% of all surgery patients in the USA are receiving opioids going into surgery. The number of patients on medication maintenance therapy with long-acting opioids such as methadone or partial mu receptor agonists like buprenorphine is rising, which poses a challenge for perioperative healthcare providers.

Recent Findings

Preoperative opioid tolerance is an independent predictor for increased length of hospital stays, high costs, and increased readmission rates following surgery. Given the recent trends, it is likely that more opioid-tolerant patients will require surgery in near future. Enhanced recovery programs can be used to provide a framework for high-quality care to opioid-tolerant patients throughout all phases of the perioperative process. To improve the quality of care of opioid-tolerant patients, we present five general recommendations for clinicians to consider and possibly incorporate into ERAS programs and care protocols.

Summary

Recommendations include the following: opioid-tolerant patients should not be excluded from ERAS programs; opioid-tolerant patients should be identified preoperatively; programs should establish standard practices for patients on medication maintenance therapy and buprenorphine; opioid-tolerant patients should receive multimodal analgesia perioperatively; and opioid-tolerant patients should receive coordinated follow up after surgery.

Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths--United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64:1378–82.CrossRef

Manchikanti L, Fellows B, Ailinani H, Pampati V. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010;13:401–35.PubMed

• Ahrnsbrak R, Bose J, Hedden S, Lipari R, Park-Lee E. Key substance use and mental health indicators in the United States: Results from the 2016 National Survey on Drug Use and Health [Internet]. Substance Abuse and Mental Health Services Administration (SAMHSA); 2017. Available from: https://www.samhsa.gov/data/. Accessed 15 April 2020. Important national survey of drug use and health.

Waljee JF, Cron DC, Steiger RM, Zhong L, Englesbe MJ, Brummett CM. Effect of preoperative opioid exposure on healthcare utilization and expenditures following elective abdominal surgery. Ann Surg. 2017;265:715–21.CrossRef

•• Jonan AB, Kaye AD, Urman RD. Buprenorphine formulations: Clinical best practice strategies recommendations for perioperative management of patients undergoing surgical or interventional pain procedures. Pain Physician. 2018;21:E1–12. Best practice strategies for patients undergoing surgery or interventional procedures on buprenorphine. PubMed

Gulur P, Williams L, Chaudhary S, Koury K, Jaff M. Opioid tolerance--a predictor of increased length of stay and higher readmission rates. Pain Physician. 2014;17:E503–7.PubMed

Cron DC, Englesbe MJ, Bolton CJ, Joseph MT, Carrier KL, Moser SE, et al. Preoperative opioid use is independently associated with increased costs and worse outcomes after major abdominal surgery. Ann Surg. 2017;265:695–701.CrossRef

Urman RD, Seger DL, Fiskio JM, Neville BA, Harry EM, Weiner SG, et al. The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients. J Patient Saf. 2019. https://doi.org/10.1097/PTS.0000000000000566.

Stone AB, Jones MR, Rao N, Urman RD. A dashboard for monitoring opioid-related adverse drug events following surgery using a National Administrative Database. Am J Med Qual. 2019;34:45–52. https://doi.org/10.1177/1062860618782646.

10.

Kaye AD, Helander EM, Vadivelu N, Lumermann L, Suchy T, Rose M, et al. Consensus statement for clinical pathway development for perioperative pain management and care transitions. Pain Ther. 2017;6:129–41. https://doi.org/10.1007/s40122-017-0079-0.

11.

Kaye AD, Jones MR, Kaye AM, Ripoll JG, Jones DE, Galan V, et al. Prescription opioid abuse in chronic pain: an updated review of opioid abuse predictors and strategies to curb opioid abuse (Part 2). Pain Physician. 2017;20:S111–S133.

12.

Kaye AD, Jones MR, Kaye AM, Ripoll JG, Galan V, Beakley BD, et al. Prescription opioid abuse in chronic pain: an updated review of opioid abuse predictors and strategies to curb opioid abuse: Part 1. Pain Physician. 2017;20:S93–S109. (Review).

13.

Katz J, Weinrib A, Fashler SR, Katznelzon R, Shah BR, Ladak SS, et al. The Toronto general hospital transitional pain service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res. 2015;8:695–702.CrossRef

14.

Aronson S, Westover J, Guinn N, Setji T, Wischmeyer P, Gulur P, et al. A perioperative medicine model for population health: an integrated approach for an evolving clinical science. Anesth Analg. 2018;126:682–90.CrossRef

15.

Helander EM, Webb MP, Bias M, Whang EE, Kaye AD, Urman RD. Use of regional anesthesia techniques: analysis of institutional enhanced recovery after surgery protocols for colorectal surgery. J Laparoendosc Adv Surg Tech A. 2017;27:898–902. https://doi.org/10.1089/lap.2017.0339.

16.

Helander EM, Webb MP, Bias M, Whang EE, Kaye AD, Urman RD. A comparison of multimodal analgesic approaches in institutional enhanced recovery after surgery protocols for colorectal surgery: pharmacological agents. J Laparoendosc Adv Surg Tech A. 2017;27:903–8. https://doi.org/10.1089/lap.2017.0338.

17.

•• Soffin EM, Lee BH, Kumar KK, Wu CL. The prescription opioid crisis: role of the anaesthesiologist in reducing opioid use and misuse. Br J Anaesth. 2019;122:e198–e208. https://doi.org/10.1016/j.bja.2018.11.019. Interesting article on the role of the anesthesiologist in reducing opioid use and misuse.

18.

Pirrera B, Lucchi A, Gabbianelli C, Alagna V, Martorelli G, Berti P, et al. E.R.A.S. pathway in colorectal surgery in elderly: Our experience: A retrospective cohort study. Int J Surg Lond Engl. 2017;43:101–6.CrossRef

19.

Day RW, Fielder S, Calhoun J, Kehlet H, Gottumukkala V, Aloia TA. Incomplete reporting of enhanced recovery elements and its impact on achieving quality improvement. Br J Surg. 2015;102:1594–602.CrossRef

20.

Labgaa I, Jarrar G, Joliat GR, Allemann P, Gander S, Blanc C, et al. Implementation of enhanced recovery (ERAS) in colorectal surgery has a positive impact on Non-ERAS liver surgery patients. World J Surg. 2016;40:1082–91. https://doi.org/10.1007/s00268-015-3363-3.

21.

Simpson G, Jackson M. Perioperative management of opioid-tolerant patients. BJA Educ. 2017;17:124–8.CrossRef

22.

Anderson TA, Quaye ANA, Ward EN, Wilens TE, Hilliard PE, Brummett CM. To stop or not, that is the question: acute pain management for the patient on chronic buprenorphine. Anesthesiology. 2017;126:1180–6.CrossRef

23.

Ward EN, Quaye AN-A, Wilens TE. Opioid use disorders: perioperative management of a special population. Anesth Analg. 2018;127:539–47.CrossRef

24.

Goel A, Azargive S, Weissman JS, Shanthanna H, Hanlon JG, Samman B, et al. Perioperative pain and addiction interdisciplinary network (PAIN) clinical practice advisory for perioperative management of buprenorphine: results of a modified Delphi process. Br J Anaesth [Internet]. 2019 [cited 2019 Jun 27]; Available from: https://linkinghub.elsevier.com/retrieve/pii/S0007091219303253. Accessed 15 April 2020.

25.

Wick EC, Galante DJ, Hobson DB, Benson AR, Lee KK, Berenholtz SM, et al. Organizational culture changes result in improvement in patient-centered outcomes: implementation of an integrated recovery pathway for surgical patients. J Am Coll Surg. 2015;221:669–77.CrossRef

26.

McEvoy MD, Scott MJ, Gordon DB, Grant SA, Thacker JKM, Wu CL, et al. American Society for Enhanced Recovery (ASER) and perioperative quality initiative (POQI) joint consensus statement on optimal analgesia within an enhanced recovery pathway for colorectal surgery: part 1-from the preoperative period to PACU. Perioper Med Lond Engl. 2017;6:8.CrossRef

27.

Malik OS, Kaye AD, Urman RD. Perioperative Hyperalgesia and associated clinical factors. Curr Pain Headache Rep. 2017;21:4.CrossRef

28.

Doverty M, Somogyi AA, White JM, Bochner F, Beare CH, Menelaou A, et al. Methadone maintenance patients are cross-tolerant to the antinociceptive effects of morphine. Pain. 2001;93:155–63.CrossRef

29.

Grant MC, Pio Roda CM, Canner JK, Sommer P, Galante D, Hobson D, et al. The impact of anesthesia-influenced process measure compliance on length of stay: results from an enhanced recovery after surgery for colorectal surgeryCohort. Anesth Analg. 2019;128:68–74. https://doi.org/10.1213/ANE.0000000000003458.

30.

Levy N, Lobo DN, Fawcett WJ, Ljungqvist O, Scott MJ. Opioid stewardship: a need for opioid discharge guidance. Comment on Br J Anaesth 2019; 122. Br J Anaesth. 2019;

Title: Recommendations for Managing Opioid-Tolerant Surgical Patients within Enhanced Recovery Pathways
Authors: Alexander Stone
Antonia Roberts
Hans D. de Boer
Alan D. Kaye
William J. Fawcett
Richard D. Urman
Publication date: 01-06-2020
Publisher: Springer US
Keywords: Buprenorphine
Opioids
Opioids
Maintenance Therapy
Published in: Current Pain and Headache Reports / Issue 6/2020
Print ISSN: 1531-3433
Electronic ISSN: 1534-3081
DOI: https://doi.org/10.1007/s11916-020-00856-w

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Recommendations for Managing Opioid-Tolerant Surgical Patients within Enhanced Recovery Pathways

Abstract

Purpose of Review

Recent Findings

Summary

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose of Review

Recent Findings

Summary

Please log in to get access to this content

Other articles of this Issue 6/2020

The ALblation Technique for Treating Migraine Headache

A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache

Is a One Prognostic Block Sufficient to Proceed with Radiofrequency Ablation? A Single Center Experience

Is Percutaneous Adhesiolysis Effective in Managing Chronic Low Back and Lower Extremity Pain in Post-surgery Syndrome: a Systematic Review and Meta-analysis

Does Epidural Bupivacaine with or Without Steroids Provide Long-Term Relief? A Systematic Review and Meta-analysis

Effects of Tourniquets in the Development of Pain States: a Novel Clinical Pilot Study and Review of Utilization of Tissue Oximetry to Measure Neural Ischemia