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

  • Other Pain (AD. Kaye and N Vadivelu, Section Editors)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

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.

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Authors and Affiliations

  1. Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA

    Alexander Stone & Richard D. Urman

  2. Department of Obstetrics and Gynecology, Naval Medical Center, San Diego, CA, USA

    Antonia Roberts

  3. Department of Anesthesiology, Pain Medicine and Procedural Sedation and Analgesia, Martini General Hospital, Groningen, The Netherlands

    Hans D. de Boer

  4. Department of Anesthesiology and Pharmacology, Toxicology, and Neurosciences, Louisiana State University School of Medicine, Shreveport, LA, USA

    Alan D. Kaye

  5. Department of Anaesthesia, Royal Surrey County Hospital, Guildford, GU2 7XX, UK

    William J. Fawcett

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Correspondence to Richard D. Urman.

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Conflict of Interest

RU has received research funding from Medtronic, Mallinckrodt, Merck, and honorarium from 3 M. WJF reports honoraria from Merck, Baxter, Grunethal, and Smiths for lecturing and travel expenses. Alexander Stone, Antonia Roberts, Hans D. de Boer, William J. Fawcett, and Richard D. Urman declare no conflict of interest. Alan Kaye is a Section Editor for Current Pain and Headache Reports. He has not been involved in the review process for the manuscript.

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Stone, A., Roberts, A., de Boer, H.D. et al. Recommendations for Managing Opioid-Tolerant Surgical Patients within Enhanced Recovery Pathways. Curr Pain Headache Rep 24, 28 (2020). https://doi.org/10.1007/s11916-020-00856-w

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