Anesthesia Alert: Caring for Patients With Opioid Use Disorder

More than 2 million Americans suffer from opioid-use disorder — and that might be a conservative estimate. This has led to a dramatic increase in patients presenting for surgery who are illicitly using opioids or in recovery from a problematic pattern of opioid use. Don't fall into the trap of treating these individuals like opioid na??ve patients. Improving pain management protocols for patients with opioid use disorder will lead to vast improvements in the care they receive, save lives and protect the sobriety they have worked so hard to rebuild. ?

1 Understand the risks

Surgery is an especially stressful time for patients with opioid use disorder. They worry about the success of the procedure and complications from anesthesia like everyone else, but also face the risk of relapse from exposure to opioids given during or after surgery.

In addition, opioid use disorder causes changes to the nervous system that make providing anesthesia and managing pain particularly challenging. The American Psychiatric Society lists some of the symptoms of opioid use disorder as increased tolerance to opioids and sensitivity to pain. Additionally, the standard treatment for opioid use disorder includes medication-assisted therapy, which includes buprenorphine/naloxone or naltrexone. These medications block the opioid receptors and make using opioids to treat pain even less effective.

It's clear opioids aren't effective at controlling pain in patients with opioid use disorder. It's also ethically unsupportable to expose them to the drug of their addiction without first exhausting all other efforts at controlling their pain.

2 Improve communication

Care of the patient with opioid use disorder is still a subjective area that must be guided by the best evidence of addictionology, pain management and anesthesiology.

Surgical professionals are often slow to adapt and with the stigma surrounding opioids today, many providers don't screen for opioid use disorder. Ideally, surgeons should screen patients during initial clinic visits, and alert surgical facilities and anesthesia teams when surgeries are scheduled for patients with the disorder.

Given the difficulties the disorder can cause, these patients should be assessed by your anesthesia team, and their care should be coordinated among the surgeon, anesthesia provider ?and an addictionologist before they arrive on the day of surgery. That way, there will already be a plan in place for managing patients' pain in the facility and when they go home after surgery.

It's ethically unsupportable to expose them to the drug of their addiction.

When a patient with opioid use disorder is scheduled for surgery, set up a group consult with their surgeon, addictionologist and anesthesia provider to develop an individual care plan. It's not uncommon for a patient with opioid use disorder to show up for surgery with the care team having no advanced warning of their condition. Likewise, the patient's addictionologist often has no idea the patient is going to be having surgery, or does not provide recommendations for holding or continuing their medication-assisted therapy during this time. Improved communication among members of the care team well before scheduled surgeries will ensure these patients receive the extra attention they need.

3 Rely on regional anesthesia

There are two separate issues that need to be considered when caring for patients with opioid use disorder: intra- and post-op pain management. Traditionally, opioids have been used during both phases of care. Medication-assisted therapies for opioid use disorder make opioids ineffective for the treatment of surgical pain and cause patients' nervous systems to feel pain more strongly.

It's easy to manage their pain during surgery with strong medications such as ketamine, dexme-detomidine, magnesium, lidocaine infusions and esmolol, which have been shown to be very effective intraoperative options. Problems can arise after surgery, however, because many of these medications have unpleasant side effects and are only available in IV form, which limits the practicality of using them outside of the OR.

Peripheral nerve blocks are one effective option for post-op pain management. Consider placing blocks during procedures, which is not a common practice. Additionally, instead of administering a single injection of medication for a peripheral nerve block that will last 12 to 24 hours, consider placing a continuous neve block and catheter, and sending patients home with a pain pump that will infuse analgesic medications for three to five days.

Take the time and make the effort to deliver the appropriate care to these patients. Treating them in the same manner as opioid na??ve patients subjects them to inadequate pain management and increases their risk of relapse. Optimize their pain management with peripheral nerve blocks and multimodal medications. Anticipate a delayed discharge from PACU from needing to spend additional time controlling their pain or teaching and reinforcing their post-op pain management strategies.

Pain is a complex phenomenon and most healthcare providers are woefully under-educated on how it works and how to address it. They often treat post-op pain with opioids because that's all they have been taught to do. Patients with opioid use disorder are at high risk of relapse and uncontrolled pain after surgery. Opioid-free anesthesia, peripheral nerve blocks and multimodal therapy are all necessary to manage their pain and minimize their chances of suffering a setback. These patients deserve to be treated in facilities capable of providing a higher level of personalized care. OSM