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Perioperative Medicine
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Open Access 01-12-2017 | Review

Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol

Author: Heath McAnally

Published in: Perioperative Medicine | Issue 1/2017

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Abstract

The practice of chronic opioid prescription for chronic non-cancer pain has come under considerable scrutiny within the past several years as mounting evidence reveals a generally unfavorable risk to benefit ratio and the nation reels from the grim mortality statistics associated with the opioid epidemic. Patients struggling with chronic pain tend to use opioids and also seek out operative intervention for their complaints, which combination may be leading to increased postoperative “acute-on-chronic” pain and fueling worsened chronic pain and opioid dependence.
Besides worsened postoperative pain, a growing body of literature, reviewed herein, indicates that preoperative opioid use is associated with significantly worsened surgical outcomes, and severely increased financial drain on an already severely overburdened healthcare budget. Conversely, there is evidence that preoperative opioid reduction may result in substantial improvements in outcome. In the era of accountable care, efforts such as the Enhanced Recovery After Surgery (ERAS) protocol have been introduced in an attempt to standardize and facilitate evidence-based perioperative interventions to optimize surgical outcomes. We propose that addressing preoperative opioid reduction as part of a targeted optimization approach for chronic pain patients seeking surgery is not only logical but mandatory given the stakes involved. Simple opioid reduction/abstinence however is not likely to occur in the absence of provision of viable and palatable alternatives to managing pain, which will require a strong focus upon reducing pain catastrophization and bolstering self-efficacy and resilience.
In response to a call from our surgical community toward that end, we have developed a simple and easy-to-implement outpatient preoperative optimization program focusing on gentle opioid weaning/elimination as well as a few other high-yield areas of intervention, requiring a minimum of resources.
Literature
Aasvang EK, Lunn TH, Hansen TB, Kristensen PW, Solgaard S, Kehlet H. Chronic pre-operative opioid use and acute pain after fast-track total knee arthroplasty. Acta Anaesthesiol Scand. 2016;60:529–36.CrossRefPubMed
Abbott AD, Tyni-Lenne R, Hedlund R. Leg pain and psychological variables predict outcome 2–3 years after lumbar fusion surgery. Eur Spine J. 2011;20:1626–34.CrossRefPubMedPubMedCentral
Adriaensen H, Vissers K, Noorduin H, Meert T. Opioid tolerance and dependence: an inevitable consequence of chronic treatment? Acta Anaesthesiol Belg. 2003;54:37–47.PubMed
Anderson PA, Subach BR, Riew KD. Predictors of outcome after anterior cervical discectomy and fusion: a multivariate analysis. Spine (Phila Pa 1976). 2009;34:161–6.CrossRef
Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104:570–87.CrossRefPubMed
Angst MS, Koppert W, Pahl I, Clark DJ, Schmelz M. Short-term infusion of the mu-opioid agonist remifentanil in humans causes hyperalgesia during withdrawal. Pain. 2003;106:49–57.CrossRefPubMed
Apkarian AV, Bushnell MC, Treede RD, Zubieta JK. Human brain mechanisms of pain perception and regulation in health and disease. Eur J Pain. 2005;9:463–84.CrossRefPubMed
Apkarian AV, Hashmi JA, Baliki MN. Pain and the brain: specificity and plasticity of the brain in clinical chronic pain. Pain. 2011;152(3 Suppl):S49–64.CrossRefPubMed
Apkarian AV, Sosa Y, Sonty S, Levy RE, Harden RN, Parrish TB, et al. Chronic back pain is associated with decreased prefrontal and thalamic gray matter density. J Neurosci. 2004;24:10410–5.CrossRefPubMed
Arteta J, Cobos B, Hu Y, Jordan K, Howard K. Evaluation of how depression and anxiety mediate the relationship between pain catastrophizing and prescription opioid misuse in a chronic pain population. Pain Med. 2016;17:295–303.PubMed
Attal N, Masselin-Dubois A, Martinez V, Jayr C, Albi A, Fermanian J, et al. Does cognitive functioning predict chronic pain? Results from a prospective surgical cohort. Brain. 2014;137:904–17.CrossRefPubMed
Baliki MN, Petre B, Torbey S, Herrmann KM, Huang L, Schnitzer TJ, et al. Corticostriatal functional connectivity predicts transition to chronic back pain. Nat Neurosci. 2012;15:1117–9.CrossRefPubMedPubMedCentral
Becker WC, Sullivan LE, Tetrault JM, Desai RA, Fiellin DA. Non-medical use, abuse and dependence on prescription opioids among U.S. adults: psychiatric, medical and substance use correlates. Drug Alcohol Depend. 2008;94:38–47.CrossRefPubMed
Ben-Ari A, Chansky H, Rozet I. Preoperative opioid use is associated with early revision after total knee arthroplasty: a study of male patients treated in the veterans affairs system. J Bone Joint Surg Am. 2017;99:1–9.CrossRefPubMed
Blanco C, Rafful C, Wall MM, Jin CJ, Kerridge B, Schwartz RP. The latent structure and predictors of non-medical prescription drug use and prescription drug use disorders: a national study. Drug Alcohol Depend. 2013;133:473–9.CrossRefPubMed
Carroll I, Barelka P, Wang CK, Wang BM, Gillespie MJ, McCue R. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115:694–702.PubMed
Chan FJ, Schwartz AM, Wong J, Chen C, Tiwari B, Kim SJ. Use of chronic methadone before total knee arthroplasty. J Arthroplast. 2017;32:2105–7.CrossRef
Chapman CR, Davis J, Donaldson GW, Naylor J, Winchester D. Postoperative pain trajectories in chronic pain patients undergoing surgery: the effects of chronic opioid pharmacotherapy on acute pain. J Pain. 2011;12:1240–6.CrossRefPubMed
Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147:478–91. Erratum in: Ann Intern Med. 2008;148:247-8CrossRefPubMed
Comelon M, Raeder J, Stubhaug A, Nielsen CS, Draegni T, Lenz H, Colvin L. Gradual withdrawal of remifentanil infusion may prevent opioid-induced hyperalgesia. Br J Anaesth. 2016;116:524–30.CrossRefPubMed
Compton P, Athanasos P, Elashoff D. Withdrawal hyperalgesia after acute opioid physical dependence in nonaddicted humans: a preliminary study. J Pain. 2003;4:511–9.CrossRefPubMed
Cooper ZD, Sullivan MA, Vosburg SK, Manubay JM, Haney M, Foltin RW, et al. Effects of repeated oxycodone administration on its analgesic and subjective effects in normal, healthy volunteers. Behav Pharmacol. 2012;23:271–9.CrossRefPubMedPubMedCentral
Coronado RA, George SZ, Devin CJ, et al. Pain sensitivity and pain catastrophizing are associated with persistent pain and disability after lumbar spine surgery. Arch Phys Med Rehabil. 2015;96:1763–70.CrossRefPubMedPubMedCentral
Darnall BD. Pain psychology and pain catastrophizing in the perioperative setting: a review of impacts, interventions and unmet needs. Hand Clin. 2016;32:33–9.CrossRefPubMedPubMedCentral
Denison E, Åsenlöf P, Lindberg P. Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care. Pain. 2004;111:245–52.CrossRefPubMed
Desebbe O, Lanz T, Kain Z, Cannesson M. The perioperative surgical home: an innovative, patient-centred and cost-effective perioperative care model. Anaesth Crit Care Pain Med. 2016;35:59–66.CrossRefPubMed
Faour M, Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, Ahn NU. Neck pain, preoperative opioids, and functionality after cervical fusion. Orthopedics. 2017;40:25–32.CrossRefPubMed
Fechner J, Ihmsen H, Schuttler J, Jeleazcov C. The impact of intraoperative sufentanil dosing on postoperative pain, hyperalgesia and morphine consumption after cardiac surgery. Eur J Pain. 2013;17:562–70.CrossRefPubMed
Fishbain DA, Cutler BR, Rosomoff HL, Rosomoff RS. Comorbidity between psychiatric disorders and chronic pain. Curr Rev Pain. 1998;2:1–10.CrossRef
Fletcher D, Martinez V. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a meta-analysis. Br J Anaesth. 2014;112:991–1004.CrossRefPubMed
Flor H, Braun C, Elbert T, Birbaumer N. Extensive reorganization of primary somatosensory cortex in chronic back pain patients. Neurosci Lett. 1997;224:5–8.CrossRefPubMed
Goldner EM, Lusted A, Roerecke M, Rehm J, Fischer B. Prevalence of Axis-1 psychiatric (with focus on depression and anxiety) disorder and symptomatology among non-medical prescription opioid users in substance use treatment: systematic review and meta-analyses. Addict Behav. 2014;39:520–31.CrossRefPubMed
Gross R, Long D, Cox S. (197) Predicting opioid misuse with a brief screener of catastrophizing. J Pain. 2016;17(4S):S25.CrossRef
Guignard B, Bossard AE, Coste C, Sessler DI, Lebrault C, Alfonsi P, et al. Acute opioid tolerance: intraoperative remifentanil increases postoperative pain and morphine requirement. Anesthesiology. 2000;93:409–17.CrossRefPubMed
Gureje O, Von Korff M, Kola L, Demyttenaere K, He Y, Posada-Villa J, et al. The relation between multiple pains and mental disorders: results from the world mental health surveys. Pain. 2008;135:82–91.CrossRefPubMed
Harris IA, Young JM, Rae H, Jalaludin BB, Solomon MJ. Factors associated with back pain after physical injury: a survey of consecutive major trauma patients. Spine (Phila Pa 1976). 2007;32:1561–5.CrossRef
Heinricher MM, Tavares I, Leith JL, Lumb BM. Descending control of nociception: specificity, recruitment and plasticity. Brain Res Rev. 2009;60:214–25.CrossRefPubMed
Hina N, Fletcher D, Poindessous-Jazat F, Martinez V. Hyperalgesia induced by low-dose opioid treatment before orthopaedic surgery: an observational case-control study. Eur J Anaesthesiol. 2015;32:255–61.CrossRefPubMed
Hoofwijk DM, Fiddelers AA, Peters ML, Stessel B, Kessels AG, Joosten EA, et al. Prevalence and predictive factors of chronic postsurgical pain and poor global recovery one year after outpatient surgery. Clin J Pain. 2015; Epub
Ip HY, Abrishami A, Peng PW, et al. Predictors of postoperative pain and analgesic consumption: a qualitative systematic review. Anesthesiology. 2009;111:657–77.CrossRefPubMed
Jenewein J, Moergeli H, Wittmann L, Büchi S, Kraemer B, Schnyder U. Development of chronic pain following severe accidental injury. Results of a 3-year follow-up study. J Psychosom Res. 2009;66:119–26.CrossRefPubMed
Katz C, El-Gabalawy R, Keyes KM, Martins SS, Sareen J. Risk factors for incident nonmedical prescription opioid use and abuse and dependence: results from a longitudinal nationally representative sample. Drug Alcohol Depend. 2013;132:107–13.CrossRefPubMedPubMedCentral
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.CrossRefPubMedPubMedCentral
Kelly MP, Anderson PA, Sasso RC, Riew KD. Preoperative opioid strength may not affect outcomes of anterior cervical procedures: a post hoc analysis of 2 prospective, randomized trials. J Neurosurg Spine. 2015;23:484–9.CrossRefPubMedPubMedCentral
Khan RS, Ahmed K, Blakeway E, et al. Catastrophizing: a predictive factor for postoperative pain. Am J Surg. 2011;201:122–31.CrossRefPubMed
Kleiman V, Clarke H, Katz J. Sensitivity to pain traumatization: a higher-order factor underlying pain-related anxiety, pain catastrophizing and anxiety sensitivity among patients scheduled for major surgery. Pain Res Manag. 2011;16:169–77.CrossRefPubMedPubMedCentral
Lally P, van CHM J, HWW P, Wardle J. How are habits formed: modelling habit formation in the real world. Eur J Soc Psychol. 2010;40:998–1009.CrossRef
Lawrence JT, London N, Bohlman HH, Chin KR. Preoperative narcotic use as a predictor of clinical outcome: results following anterior cervical arthrodesis. Spine (Phila Pa 1976). 2008a;(33):2074–8.
Lawrence JTR, London N, Bohlman HH, Chin KR. Preoperative narcotic use as a predictor of clinical outcome: results following anterior cervical arthrodesis. Spine. 2008b;33:2074–8.CrossRefPubMed
Lee M, Silverman SM, Hansen H, Patel VB, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14:145–61.PubMed
Malik OS, Kaye AD, Urman RD. Perioperative hyperalgesia and associated clinical factors. Curr Pain Headache Rep. 2017;21:4.CrossRefPubMed
Malinen S, Vartiainen N, Hlushchuk Y, Koskinen M, Ramkumar P, Forss N, et al. Aberrant temporal and spatial brain activity during rest in patients with chronic pain. Proc Natl Acad Sci U S A. 2010;107:6493–7.CrossRefPubMedPubMedCentral
Manchikanti L, Kaye AM, Knezevic NN, McAnally H, Slavin K, Trescot AM, et al. Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 2017;20(2S):S3–S92.PubMed
Martins SS, Fenton MC, Keyes KM, Blanco C, Zhu H, Storr CL. Mood/anxiety disorders and their association with non-medical prescription opioid use and prescription opioid use disorder: longitudinal evidence from the National Epidemiologic Study on alcohol and related conditions. Psychol Med. 2012;42:1261–72.CrossRefPubMed
Mauermann E, Filitz J, Dolder P, Rentsch KM, Bandschapp O, Ruppen W. Does Fentanyl lead to opioid-induced hyperalgesia in healthy volunteers?: a double-blind, randomized. Crossover Trial Anesthesiology. 2016;124:453–63.CrossRefPubMed
McAnally HB. Opioid dependence risk factors and risk assessment. In: McAnally HB, opioid dependence: a clinical and epidemiologic approach. New York: Springer. p. 2017.
Menendez ME, Ring D, Bateman BT. Preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery. Clin Orthop Relat Res. 2015;473:2402–12.CrossRefPubMedPubMedCentral
Morris BJ, Laughlin MS, Elkousy HA, Gartsman GM, Edwards TB. Preoperative opioid use and outcomes after reverse shoulder arthroplasty. J Shoulder Elb Surg. 2015;24:11–6.CrossRef
Morris BJ, Sciascia AD, Jacobs CA, Edwards TB. Preoperative opioid use associated with worse outcomes after anatomic shoulder arthroplasty. J Shoulder Elb Surg. 2016;25:619–23.CrossRef
Nguyen LC, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplast. 2016;31(9 Suppl):282–7.CrossRef
Pivec R, Issa K, Naziri Q, Kapadia BH, Bonutti PM, Mont MA. Opioid use prior to total hip arthroplasty leads to worse clinical outcomes. Int Orthop. 2014;38:1159–65.CrossRefPubMedPubMedCentral
Raebel MA, Newcomer SR, Reifler LM, Boudreau D, Elliott TE, DeBar L, et al. Chronic use of opioid medications before and after bariatric surgery. JAMA. 2013;310:1369–76.CrossRefPubMed
Rodriguez-Raecke R, Niemeier A, Ihle K, Ruether W, May A. Brain gray matter decrease in chronic pain is the consequence and not the cause of pain. J Neurosci. 2009;29:13746–50.CrossRefPubMed
Roeckel LA, Le Coz GM, Gavériaux-Ruff C, Simonin F. Opioid-induced hyperalgesia: cellular and molecular mechanisms. Neuroscience. 2016;338:160–82.CrossRefPubMed
Roullet S, Nouette-Gaulain K, Biais M, Bernard N, Bénard A, Revel P, et al. Preoperative opioid consumption increases morphine requirement after leg amputation. Can J Anaesth. 2009;56:908–13.CrossRefPubMed
Rozet I, Nishio I, Robbertze R, Rotter D, Chansky H, Hernandez AV. Prolonged opioid use after knee arthroscopy in military veterans. Anesth Analg. 2014;119:454–9.CrossRefPubMed
Salengros J-C, Huybrechts I, Ducart A, Faraoni D, Marsala C, Barvais L, et al. Different anesthetic techniques associated with different incidences of chronic post-thoracotomy pain: low dose remifentanil plus pre-surgical epidural analgesia is preferable to high dose remifentanil with postsurgical epidural analgesia. J Cardiothorac Vasc Anesth. 2010;24:608–16.CrossRefPubMed
Schmidt-Wilcke T. Variations in brain volume and regional morphology associated with chronic pain. Curr Rheumatol Rep. 2008;10:467–74.CrossRefPubMed
Simons LE, Elman I, Borsook D. Psychological processing in chronic pain: a neural systems approach. Neurosci Biobehav Rev. 2014;39:61–78.CrossRefPubMed
Sing DC, Barry JJ, Cheah JW, Vail TP, Hansen EN. Long-acting opioid use independently predicts perioperative complication in total joint arthroplasty. J Arthroplast. 2016;31(9 Suppl):170–4.CrossRef
Smith SR, Bido J, Collins JE, Yang H, Katz JN, Losina E. Impact of preoperative opioid use on total knee arthroplasty outcomes. J Bone Joint Surg Am. 2017;99:803–8.CrossRefPubMed
Sullivan MJL, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7:524–32.CrossRef
Teunis T, Bot AG, Thornton ER, Ring D. Catastrophic thinking is associated with finger stiffness after distal radius fracture surgery. J Orthop Trauma. 2015 Oct;29(10):e414–20.CrossRefPubMed
Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA. Preoperative anxiety and catastrophizing: a systematic review and meta-analysis of the association with chronic postsurgical pain. Clin J Pain. 2012;28:819–41.CrossRefPubMed
Tinazzi M, Zanette G, Volpato D, Testoni R, Bonato C, Manganotti P, Miniuissi C, Fiachi A. Neurophysiological evidence of neuroplasticity at multiple levels of the somatosensory system in patients with carpal tunnel syndrome. Brain. 1998;121:1785–94.CrossRefPubMed
Tracey I, Mantyh PW. The cerebral signature for pain perception and its modulation. Neuron. 2007;2:377–91.CrossRef
Trevino CM, deRoon-Cassini T, Brasel K. Does opiate use in traumatically injured individuals worsen pain and psychological outcomes? J Pain. 2013;14:424–30.CrossRefPubMed
Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain. 2008;24:497–508.CrossRefPubMed
VanDenKerkhof EG, Hopman WM, Goldstein DH, Wilson RA, Towheed TE, Lam M, et al. Impact of perioperative pain intensity, pain qualities, and opioid use on chronic pain after surgery: a prospective cohort study. Reg Anesth Pain Med. 2012;37:19–27.CrossRefPubMed
Villavicencio AT, Nelson EL, Kantha V, Burneikiene S. Prediction based on preoperative opioid use of clinical outcomes after transforaminal lumbar interbody fusions. J Neurosurg Spine. 2017;26:144–9.CrossRefPubMed
Vissers MM, Bussmann JB, Verhaar JA, Busschbach JJ, Bierma-Zeinstra SM, Reijman M. Psychological factors affecting the outcome of total hip and knee arthroplasty: a systematic review. Semin Arthritis Rheum. 2012;41:576–88.CrossRefPubMed
Von Korff N, Crane P, Lane M, Miglioretti DL, Simon G, Saunders K, et al. Chronic spinal pain and physical–mental comorbidity in the United States: results from the national comorbidity survey replication. Pain. 2005;113:331–9.CrossRefPubMed
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.CrossRefPubMed
Wanigasekera V, Lee MC, Rogers R, Hu P, Tracey I. Neural correlates of an injury-free model of central sensitization induced by opioid withdrawal in humans. J Neurosci. 2011;31:2835–42.CrossRefPubMedPubMedCentral
Weber L, Yeomans DC, Tzabazis A. Opioid-induced hyperalgesia in clinical anesthesia practice: what has remained from theoretical concepts and experimental studies? Curr Opin Anaesthesiol. 2017;30:458–65.CrossRefPubMed
Weinbroum AA. Postoperative hyperalgesia—a clinically applicable narrative review. Pharmacol Res. 2017;120:188–205.CrossRefPubMed
Williams JT, Ingram SL, Henderson G, Chavkin C, von Zastrow M, Schulz S, et al. Regulation of μ-opioid receptors: desensitization, phosphorylation, internalization, and tolerance. Pharmacol Rev. 2013;65:223–54.CrossRefPubMedPubMedCentral
Younger JW, Chu LF, D'Arcy NT, Trott KE, Jastrzab LE, Mackey SC. Prescription opioid analgesics rapidly change the human brain. Pain. 2011;152:1803–10.CrossRefPubMedPubMedCentral
Zarling BJ, Yokhana SS, Herzog DT, Markel DC. Preoperative and postoperative opiate use by the arthroplasty patient. J Arthroplast. 2016;31:2081–4.CrossRef
Zywiel MG, Stroh DA, Lee SY, Bonutti PM, Mont MA. Chronic opioid use prior to total knee arthroplasty. J Bone Joint Surg Am. 2011;93:1988–93.CrossRefPubMed
Metadata
Title
Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol
Author
Heath McAnally
Publication date
01-12-2017
Publisher
BioMed Central
Published in
Perioperative Medicine / Issue 1/2017
Electronic ISSN: 2047-0525
DOI
https://doi.org/10.1186/s13741-017-0079-y

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