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Challenges in the Optimisation of Post-operative Pain Management with Opioids in Obese Patients: a Literature Review

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Abstract

An increasing number of obese patients are undergoing surgery, particularly bariatric and orthopaedic surgery. The physiological differences between obese and normal-weight subjects may modify not only anaesthetic requirements during surgery but also post-operative analgesic management, raising a number of challenges in a critical period. In this review, we analyse studies of post-operative pain management with opioids in obese subjects. We discuss the genetic factors common to pain and obesity and the factors potentially modifying opioid pharmacokinetics and pharmacodynamics in obese patients, and we analyse the overall efficacy and safety of opioids for pain management during the post-operative period in obese patients. Both modifications to surgical methods and additional analgesic treatments to decrease the requirement for opioids may improve early rehabilitation and quality of care and reduce adverse effects in obese patients.

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References

  1. Franklin J, Ingvarsson T, Englund M, et al. Sex differences in the association between body mass index and total hip or knee joint replacement resulting from osteoarthritis. Ann Rheum Dis. 2009;68:536–40.

    Article  PubMed  CAS  Google Scholar 

  2. Cremieux PY, Buchwald H, Shikora SA, et al. A study on the economic impact of bariatric surgery. Am J Manag Care. 2008;14:589–96.

    PubMed  Google Scholar 

  3. Schug SA, Raymann A. Postoperative pain management of the obese patient. Best Pract Res Clin Anaesthesiol. 2011;25:73–81.

    Article  PubMed  CAS  Google Scholar 

  4. Carlsson LM, Peltonen M, Ahlin S, et al. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med. 2012;367:695–704.

    Article  PubMed  CAS  Google Scholar 

  5. Sjostrom L, Narbro K, Sjostrom CD, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med. 2007;357:741–52.

    Article  PubMed  Google Scholar 

  6. Nguyen NT, Root J, Zainabadi K, et al. Accelerated growth of bariatric surgery with the introduction of minimally invasive surgery. Arch Surg. 2005;140:1198–202. discussion 1203.

    Article  PubMed  Google Scholar 

  7. Samson AJ, Mercer GE, Campbell DG. Total knee replacement in the morbidly obese: a literature review. ANZ J Surg. 2010;80:595–9.

    Article  PubMed  Google Scholar 

  8. Schouten JS, van den Ouweland FA, Valkenburg HA. A 12 year follow up study in the general population on prognostic factors of cartilage loss in osteoarthritis of the knee. Ann Rheum Dis. 1992;51:932–7.

    Article  PubMed  CAS  Google Scholar 

  9. Felson DT, Zhang Y, Hannan MT, et al. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum. 1997;40:728–33.

    Article  PubMed  CAS  Google Scholar 

  10. Dougados M, Gueguen A, Nguyen M, et al. Longitudinal radiologic evaluation of osteoarthritis of the knee. J Rheumatol. 1992;19:378–84.

    PubMed  CAS  Google Scholar 

  11. Rajgopal V, Bourne RB, Chesworth BM, et al. The impact of morbid obesity on patient outcomes after total knee arthroplasty. J Arthroplasty. 2008;23:795–800.

    Article  PubMed  Google Scholar 

  12. Ingrande J, Lemmens HJ. Dose adjustment of anaesthetics in the morbidly obese. Br J Anaesth. 2010;105 Suppl 1:i16–23.

    Article  PubMed  CAS  Google Scholar 

  13. Ronellenfitsch U, Schwarzbach M, Kring A, et al. The effect of clinical pathways for bariatric surgery on perioperative quality of care. Obes Surg. 2012;22:732–9.

    Article  PubMed  Google Scholar 

  14. Priano L, Miscio G, Grugni G, et al. On the origin of sensory impairment and altered pain perception in Prader–Willi syndrome: a neurophysiological study. Eur J Pain. 2009;13:829–35.

    Article  PubMed  Google Scholar 

  15. Farooqi S, O'Rahilly S. Genetics of obesity in humans. Endocr Rev. 2006;27:710–8.

    PubMed  CAS  Google Scholar 

  16. Beckers S, Peeters A, Zegers D, et al. Association of the BDNF Val66Met variation with obesity in women. Mol Genet Metab. 2008;95:110–2.

    Article  PubMed  CAS  Google Scholar 

  17. Wu L, Xi B, Zhang M, et al. Associations of six single nucleotide polymorphisms in obesity-related genes with BMI and risk of obesity in Chinese children. Diabetes. 2010;59:3085–9.

    Article  PubMed  CAS  Google Scholar 

  18. Vossen H, Kenis G, Rutten B, et al. The genetic influence on the cortical processing of experimental pain and the moderating effect of pain status. PLoS One. 2010;5:e13641.

    Article  PubMed  Google Scholar 

  19. Lloret Linares C, Hajj A, Poitou C, et al. Pilot study examining the frequency of several gene polymorphisms involved in morphine pharmacodynamics and pharmacokinetics in a morbidly obese population. Obes Surg. 2011;21:1257–64.

    Article  PubMed  Google Scholar 

  20. Miscio G, Guastamacchia G, Brunani A, et al. Obesity and peripheral neuropathy risk: a dangerous liaison. J Peripher Nerv Syst. 2005;10:354–8.

    Article  PubMed  Google Scholar 

  21. Dodet P, Perrot S, Auvergne L, et al. Sensory impairment in obese patients? Sensitivity and pain detection thresholds for electrical stimulation after surgery-induced weight loss, and comparison with a nonobese population. Clin J Pain. 2013;29:43–9.

    Article  PubMed  Google Scholar 

  22. Stener-Victorin E, Kowalski J, Lundeberg T. A new highly reliable instrument for the assessment of pre- and postoperative gynecological pain. Anesth Analg. 2002;95:151–7. table of contents.

    Article  PubMed  Google Scholar 

  23. Lundblad H, Kreicbergs A, Jansson KA. Prediction of persistent pain after total knee replacement for osteoarthritis. J Bone Joint Surg Br. 2008;90:166–71.

    PubMed  CAS  Google Scholar 

  24. Nielsen PR, Norgaard L, Rasmussen LS, et al. Prediction of post-operative pain by an electrical pain stimulus. Acta Anaesthesiol Scand. 2007;51:582–6.

    Article  PubMed  CAS  Google Scholar 

  25. Khan F, Ng L, Gonzalez S, Hale T et al. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev 2008:CD004957.

  26. Cheville A, Chen A, Oster G, et al. A randomized trial of controlled-release oxycodone during inpatient rehabilitation following unilateral total knee arthroplasty. J Bone Joint Surg Am. 2001;83-A:572–6.

    PubMed  CAS  Google Scholar 

  27. Nunez M, Lozano L, Nunez E, et al. Total knee replacement and health-related quality of life: factors influencing long-term outcomes. Arthritis Rheum. 2009;61:1062–9.

    Article  PubMed  Google Scholar 

  28. Vincent HK, Vincent KR, Lee LW, et al. Effect of obesity on inpatient rehabilitation outcomes following total knee arthroplasty. Clin Rehabil. 2007;21:182–90.

    Article  PubMed  Google Scholar 

  29. Livhits M, Mercado C, Yermilov I, et al. Behavioral factors associated with successful weight loss after gastric bypass. Am Surg. 2010;76:1139–42.

    PubMed  Google Scholar 

  30. Chumlea WC, Guo SS, Zeller CM, et al. Total body water reference values and prediction equations for adults. Kidney Int. 2001;59:2250–8.

    PubMed  CAS  Google Scholar 

  31. Ciangura C, Bouillot JL, Lloret-Linares C, et al. Dynamics of change in total and regional body composition after gastric bypass in obese patients. Obesity (Silver Spring). 2010;18:760–5.

    Article  Google Scholar 

  32. Young JF, Luecke RH, Pearce BA, et al. Human organ/tissue growth algorithms that include obese individuals and black/white population organ weight similarities from autopsy data. J Toxicol Environ Health A. 2009;72:527–40.

    Article  PubMed  CAS  Google Scholar 

  33. Poirier P, Giles TD, Bray GA, et al. Obesity and cardiovascular disease: pathophysiology, evaluation, and effect of weight loss: an update of the 1997 American Heart Association Scientific Statement on Obesity and Heart Disease from the Obesity Committee of the Council on Nutrition, Physical Activity, and Metabolism. Circulation. 2006;113:898–918.

    Article  PubMed  Google Scholar 

  34. Edholm D, Kullberg J, Haenni A, et al. Preoperative 4-week low-calorie diet reduces liver volume and intrahepatic fat, and facilitates laparoscopic gastric bypass in morbidly obese. Obes Surg. 2011;21:345–50.

    Article  PubMed  Google Scholar 

  35. Valensi P, Assayag M, Busby M, et al. Microalbuminuria in obese patients with or without hypertension. Int J Obes Relat Metab Disord. 1996;20:574–9.

    PubMed  CAS  Google Scholar 

  36. Ribstein J, du Cailar G, Mimran A. Combined renal effects of overweight and hypertension. Hypertension. 1995;26:610–5.

    Article  PubMed  CAS  Google Scholar 

  37. Chagnac A, Weinstein T, Korzets A, et al. Glomerular hemodynamics in severe obesity. Am J Physiol Renal Physiol. 2000;278:F817–822.

    PubMed  CAS  Google Scholar 

  38. Fabbrini E, Sullivan S, Klein S. Obesity and nonalcoholic fatty liver disease: biochemical, metabolic, and clinical implications. Hepatology. 2010;51:679–89.

    Article  PubMed  CAS  Google Scholar 

  39. Tilg H, Kaser A. Gut microbiome, obesity, and metabolic dysfunction. J Clin Invest. 2011;121:2126–32.

    Article  PubMed  CAS  Google Scholar 

  40. Lumeng CN, Saltiel AR. Inflammatory links between obesity and metabolic disease. J Clin Invest. 2011;121:2111–7.

    Article  PubMed  CAS  Google Scholar 

  41. Lickteig AJ, Slitt AL, Arkan MC, et al. Differential regulation of hepatic transporters in the absence of tumor necrosis factor-alpha, interleukin-1beta, interleukin-6, and nuclear factor-kappaB in two models of cholestasis. Drug Metab Dispos. 2007;35:402–9.

    Article  PubMed  CAS  Google Scholar 

  42. Vee ML, Lecureur V, Stieger B, et al. Regulation of drug transporter expression in human hepatocytes exposed to the proinflammatory cytokines tumor necrosis factor-alpha or interleukin-6. Drug Metab Dispos. 2009;37:685–93.

    Article  PubMed  Google Scholar 

  43. More VR, Slitt AL. Alteration of hepatic but not renal transporter expression in diet-induced obese mice. Drug Metab Dispos. 2011;39:992–9.

    Article  PubMed  CAS  Google Scholar 

  44. Buechler C, Weiss TS. Does hepatic steatosis affect drug metabolizing enzymes in the liver? Curr Drug Metab. 2011;12:24–34.

    Article  PubMed  CAS  Google Scholar 

  45. Sugioka N, Haraya K, Fukushima K, et al. Effects of obesity induced by high-fat diet on the pharmacokinetics of nelfinavir, a HIV protease inhibitor, in laboratory rats. Biopharm Drug Dispos. 2009;30:532–41.

    Article  PubMed  CAS  Google Scholar 

  46. Nawa A, Fujita-Hamabe W, Tokuyama S. Altered intestinal P-glycoprotein expression levels in a monosodium glutamate-induced obese mouse model. Life Sci. 2011;89:834–8.

    Article  PubMed  CAS  Google Scholar 

  47. Cheng Q, Aleksunes LM, Manautou JE, et al. Drug-metabolizing enzyme and transporter expression in a mouse model of diabetes and obesity. Mol Pharm. 2008;5:77–91.

    Article  PubMed  CAS  Google Scholar 

  48. Brill MJ, Diepstraten J, van Rongen A, et al. Impact of obesity on drug metabolism and elimination in adults and children. Clin Pharmacokinet. 2012;51:277–304.

    Article  PubMed  CAS  Google Scholar 

  49. Hanley MJ, Abernethy DR, Greenblatt DJ. Effect of obesity on the pharmacokinetics of drugs in humans. Clin Pharmacokinet. 2010;49:71–87.

    Article  PubMed  CAS  Google Scholar 

  50. Lloret Linares C, Decleves X, Oppert JM, et al. Pharmacology of morphine in obese patients: clinical implications. Clin Pharmacokinet. 2009;48:635–51.

    Article  PubMed  Google Scholar 

  51. Graves DA, Batenhorst RL, Bennett RL, et al. Morphine requirements using patient-controlled analgesia: influence of diurnal variation and morbid obesity. Clin Pharm. 1983;2:49–53.

    PubMed  CAS  Google Scholar 

  52. Tateishi T, Krivoruk Y, Ueng YF, et al. Identification of human liver cytochrome P-450 3A4 as the enzyme responsible for fentanyl and sufentanil N-dealkylation. Anesth Analg. 1996;82:167–72.

    PubMed  CAS  Google Scholar 

  53. Schwartz AE, Matteo RS, Ornstein E, et al. Pharmacokinetics of sufentanil in obese patients. Anesth Analg. 1991;73:790–3.

    PubMed  CAS  Google Scholar 

  54. Slepchenko G, Simon N, Goubaux B, et al. Performance of target-controlled sufentanil infusion in obese patients. Anesthesiology. 2003;98:65–73.

    Article  PubMed  CAS  Google Scholar 

  55. Shibutani K, Inchiosa Jr MA, Sawada K, et al. Pharmacokinetic mass of fentanyl for postoperative analgesia in lean and obese patients. Br J Anaesth. 2005;95:377–83.

    Article  PubMed  CAS  Google Scholar 

  56. Murugan AT, Sharma G. Obesity and respiratory diseases. Chron Respir Dis. 2008;5:233–42.

    Article  PubMed  CAS  Google Scholar 

  57. Juvin P, Lavaut E, Dupont H, et al. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97:595–600. table of contents.

    Article  PubMed  Google Scholar 

  58. Ahmad S, Nagle A, McCarthy RJ, et al. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2008;107:138–43.

    Article  PubMed  Google Scholar 

  59. El Shobary H, Christou N, Backman SB, et al. Effect of laparoscopic versus open gastric bypass surgery on postoperative pain and bowel function. Obes Surg. 2006;16:437–42.

    Article  PubMed  Google Scholar 

  60. Rawal N, Sjostrand U, Christoffersson E, et al. Comparison of intramuscular and epidural morphine for postoperative analgesia in the grossly obese: influence on postoperative ambulation and pulmonary function. Anesth Analg. 1984;63:583–92.

    PubMed  CAS  Google Scholar 

  61. Brodsky JB, Merrell RC. Epidural administration of morphine postoperatively for morbidly obese patients. West J Med. 1984;140:750–3.

    PubMed  CAS  Google Scholar 

  62. Kyzer S, Ramadan E, Gersch M, et al. Patient-controlled analgesia following vertical gastroplasty: a comparison with intramuscular narcotics. Obes Surg. 1995;5:18–21.

    Article  PubMed  Google Scholar 

  63. Choi YK, Brolin RE, Wagner BK, et al. Efficacy and safety of patient-controlled analgesia for morbidly obese patients following gastric bypass surgery. Obes Surg. 2000;10:154–9.

    Article  PubMed  CAS  Google Scholar 

  64. Michaloudis D, Fraidakis O, Petrou A, et al. Continuous spinal anesthesia/analgesia for perioperative management of morbidly obese patients undergoing laparotomy for gastroplastic surgery. Obes Surg. 2000;10:220–9.

    Article  PubMed  CAS  Google Scholar 

  65. Charghi R, Backman S, Christou N, et al. Patient controlled i.v. analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia. Can J Anaesth. 2003;50:672–8.

    Article  PubMed  Google Scholar 

  66. Pathiraja C, Silva N, Sharpe G, et al. Is continuous infiltration of local anaesthetic/PCA an acceptable alternate pain management strategy in morbidly obese patients undergoing gastric bypass surgery? A retrospective comparison with epidural analgesia. Sri Lankan Journal of Anaesthesiology. 2010;18:66–71.

    Article  Google Scholar 

  67. De Baerdemaeker LE, Jacobs S, Pattyn P, et al. Influence of intraoperative opioid on postoperative pain and pulmonary function after laparoscopic gastric banding: remifentanil TCI vs sufentanil TCI in morbid obesity. Br J Anaesth. 2007;99:404–11.

    Article  PubMed  Google Scholar 

  68. Bidgoli J, Delesalle S, De Hert SG, et al. A randomised trial comparing sufentanil versus remifentanil for laparoscopic gastroplasty in the morbidly obese patient. Eur J Anaesthesiol. 2011;28:120–4.

    Article  PubMed  CAS  Google Scholar 

  69. Cottam DR, Fisher B, Atkinson J, et al. A randomized trial of bupivicaine pain pumps to eliminate the need for patient controlled analgesia pumps in primary laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2007;17:595–600.

    Article  PubMed  Google Scholar 

  70. Kamal H. Ketamine as an adjuvant to morphine for patient controlled analgesia in morbidly obese patients. Journal of Medical Sciences. 2008;8:364–70.

    Article  CAS  Google Scholar 

  71. Sollazzi L, Modesti C, Vitale F, et al. Preinductive use of clonidine and ketamine improves recovery and reduces postoperative pain after bariatric surgery. Surg Obes Relat Dis. 2009;5:67–71.

    Article  PubMed  Google Scholar 

  72. Govindarajan R, Ghosh B, Sathyamoorthy MK, et al. Efficacy of ketorolac in lieu of narcotics in the operative management of laparoscopic surgery for morbid obesity. Surg Obes Relat Dis. 2005;1:530–5. discussion 535–536.

    Article  PubMed  Google Scholar 

  73. Kamelgard JI, Kim KA, Atlas G. Combined preemptive and preventive analgesia in morbidly obese patients undergoing open gastric bypass: a pilot study. Surg Obes Relat Dis. 2005;1:12–6.

    Article  PubMed  Google Scholar 

  74. Feld JM, Hoffman WE, Stechert MM, et al. Fentanyl or dexmedetomidine combined with desflurane for bariatric surgery. J Clin Anesth. 2006;18:24–8.

    Article  PubMed  CAS  Google Scholar 

  75. Tufanogullari B, White PF, Peixoto MP, et al. Dexmedetomidine infusion during laparoscopic bariatric surgery: the effect on recovery outcome variables. Anesth Analg. 2008;106:1741–8.

    Article  PubMed  CAS  Google Scholar 

  76. Cabrera Schulmeyer MC, de la Maza J, Ovalle C, et al. Analgesic effects of a single preoperative dose of pregabalin after laparoscopic sleeve gastrectomy. Obes Surg. 2010;20:1678–81.

    Article  PubMed  Google Scholar 

  77. Strayhorn G. Transcutaneous electrical nerve stimulation and postoperative use of narcotic analgesics. J Natl Med Assoc. 1983;75:811–6.

    PubMed  CAS  Google Scholar 

  78. Batistich S, Kendall A, Somers S. Analgesic requirements in morbidly obese patients. Anaesthesia. 2004;59:510–1.

    Article  PubMed  CAS  Google Scholar 

  79. Lee WJ, Huang MT, Yu PJ, et al. Laparoscopic vertical banded gastroplasty and laparoscopic gastric bypass: a comparison. Obes Surg. 2004;14:626–34.

    Article  PubMed  Google Scholar 

  80. Hamza MA, Schneider BE, White PF, et al. Heated and humidified insufflation during laparoscopic gastric bypass surgery: effect on temperature, postoperative pain, and recovery outcomes. J Laparoendosc Adv Surg Tech A. 2005;15:6–12.

    Article  PubMed  Google Scholar 

  81. Savel RH, Balasubramanya S, Lasheen S, et al. Beneficial effects of humidified, warmed carbon dioxide insufflation during laparoscopic bariatric surgery: a randomized clinical trial. Obes Surg. 2005;15:64–9.

    Article  PubMed  Google Scholar 

  82. Weingarten TN, Sprung J, Flores A, et al. Opioid requirements after laparoscopic bariatric surgery. Obes Surg. 2011;21:1407–12.

    Article  PubMed  Google Scholar 

  83. Steinmiller CL, Diederichs C, Roehrs TA, et al. Postsurgical patient-controlled opioid self-administration is greater in hospitalized abstinent smokers than nonsmokers. J Opioid Manag. 2012;8:227–35.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. INSERM U705, CNRS UMR 8206, Neuropsychopharmacology of Drug Addiction, Faculty of Pharmacy, University Paris Descartes, Paris, 75006, France

    C. Lloret-Linares, A. Lopes, S. Mouly & J.-F. Bergmann

  2. Hôpital Lariboisière, Unit of Therapeutic Research, Department of Internal Medicine, Assistance Publique-Hôpitaux de Paris, 2 rue Ambroise, Paris, 75010, France

    C. Lloret-Linares, X. Declèves, A. Serrie, S. Mouly & J.-F. Bergmann

  3. Hôpital Lariboisière, Centre de Traitement et d’Evaluation de la Douleur, Assistance Publique-Hôpitaux de Paris, Paris, 75010, France

    A. Serrie

  4. Hôpital Cochin-Hotel-Dieu, Centre de Traitement et d’Evaluation de la Douleur, Assistance Publique-Hôpitaux de Paris, Paris, 75004, France

    S. Perrot

  5. INSERM: U 987, physio-pharmacologie de la douleur, Hôpital Ambroise Paré, Boulogne-Billancourt, 92100, Paris, France

    S. Perrot

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  1. C. Lloret-Linares
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  2. A. Lopes
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  3. X. Declèves
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Correspondence to C. Lloret-Linares.

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Lloret-Linares, C., Lopes, A., Declèves, X. et al. Challenges in the Optimisation of Post-operative Pain Management with Opioids in Obese Patients: a Literature Review. OBES SURG 23, 1458–1475 (2013). https://doi.org/10.1007/s11695-013-0998-8

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