Purpose of Review

With the widespread growth of ambulatory surgery centers (ASCs), the number and diversity of operations performed in the outpatient setting continue to increase. In parallel, there is an increase in the proportion of patients with a history of chronic opioid use and misuse undergoing elective surgery. Patients with such opioid tolerance present a unique challenge in the ambulatory setting, given their increased requirement for postoperative opioids. Guidelines for managing perioperative pain, anticipating postoperative opioid requirements and a discharge plan to wean off of opioids, are therefore needed.

Recent Findings

Expert guidelines suggest using multimodal analgesia including non-opioid analgesics and regional/neuraxial anesthesia whenever possible. However, there exists variability in care, resulting in challenges in perioperative pain management. In a recent study of same-day admission patients, anesthesiologists correctly identified most opioid-tolerant patients, but used non-opioid analgesics only half the time. The concept of a focused ambulatory pain specialist on site at each ASC has been suggested, who in addition to providing safe anesthesia, could intervene early once problematic pain issues are recognized.

Summary

This review focuses on perioperative pain management in three subsets of patients who exhibit opioid tolerance: those on large doses of opioids (including abuse-deterrent formulations) for chronic non-malignant or malignant pain; those who have ongoing opioid misuse; and those who were prior addicts and are now on methadone/suboxone maintenance. We also discuss perioperative pain management for patients who have implanted devices such as spinal cord stimulators and intrathecal pain pumps.

中文翻译：

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门诊手术中心慢性疼痛患者的急性疼痛管理

审查目的

随着门诊手术中心 (ASC) 的广泛发展，门诊手术的数量和多样性不断增加。与此同时，有慢性阿片类药物使用和滥用史的患者接受择期手术的比例有所增加。鉴于患者对术后阿片类药物的需求增加，具有这种阿片类药物耐受性的患者在门诊环境中提出了独特的挑战。因此，需要制定围手术期疼痛管理指南、预测术后阿片类药物的需求以及停用阿片类药物的出院计划。

最近的发现

专家指南建议尽可能使用多模式镇痛，包括非阿片类镇痛药和区域/椎管内麻醉。然而，护理存在差异，导致围手术期疼痛管理面临挑战。在最近对同一天入院患者的一项研究中，麻醉师正确识别了大多数阿片类药物耐受患者，但只有一半的时间使用非阿片类镇痛药。已经提出了在每个 ASC 现场设有专职门诊疼痛专家的概念，除了提供安全的麻醉外，一旦发现有问题的疼痛问题，他们可以及早进行干预。

概括

本综述重点关注表现出阿片类药物耐受性的三个亚组患者的围手术期疼痛管理：大剂量阿片类药物（包括滥用威慑制剂）用于慢性非恶性或恶性疼痛；那些持续滥用阿片类药物的人；以及那些以前是瘾君子，现在正在接受美沙酮/苏博酮维持治疗的人。我们还讨论了植入脊髓刺激器和鞘内疼痛泵等设备的患者的围手术期疼痛管理。