Q&A: Anesthesia’s Effect on Surgery’s Carbon Footprint
The delivery of anesthesia care involves many single-use plastic items, vials of medications and kilowatts of electricity....
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By: Yasmine Iqbal
Published: 10/10/2007
The number of people taking opioids such as codeine, oxycodone and hydrocodone to manage chronic pain has skyrocketed in the past few years. Although these medications can make daily life bearable for people with cancer, traumatic injuries or other painful diseases and disorders, the tolerance that they develop as a result of taking them can make it much more difficult to get adequate pain relief after surgery. In this article, we'll discuss how to handle the special post-op analgesia needs of opioid-tolerant patients.
Understand tolerance
"Opioid tolerance is a natural physiologic consequence of taking these medications," says Christopher Wu, MD, associate professor of anesthesiology at the Johns Hopkins University Medical School in Baltimore. As the body adjusts to the medication, higher dosages are needed to get the desired effect. Almost everyone who takes opioids regularly will develop tolerance, adds Jeffrey Swenson, MD, associate professor of anesthesiology at the University of Utah School of Medicine in Salt Lake City. "While we can't say for sure that every patient who takes opioids is tolerant, I've never seen one who isn't," he notes.
Although tolerance isn't well understood, experts now realize that it doesn't take a lot of medication to cause it - more than four tablets of oxycodone/ acetaminophen daily or acetaminophen 300 mg/codeine 30 mg for several weeks can be enough, says Dr. Wu. It doesn't take very long to occur, either. "Some experts believe that tolerance can start building within minutes when large doses of short-acting drugs are used," says Dr. Swenson.
It's critical to identify patients who may be opioid-tolerant and recognize that they'll probably need greater and more frequent post-op doses of opioid and non-opioid agents than patients who've never taken these medications. They may also need to taper medication more gradually. "The amount of medication that these patients require is sometimes so off the scale that doctors are afraid of prescribing the correct amount because it is out of the usual standard of care," says Dr. Swenson. Withholding dosages or not administering enough will leave patients in distress and may exacerbate post-op pain. It's also important to remember that these patients are usually less affected by some effects of opioids, such as itching, nausea and vomiting, but aren't immune to dangerous effects such as respiratory depression.
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Develop a pre-op plan
Opioid-tolerant patients may be particularly concerned and even fearful about the post-op period, especially if they've experienced uncontrolled post-surgical pain before, says Dr. Swenson. So it's important to discuss pain-control options with them and develop a plan well in advance. Points to remember:
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Consider regional anesthesia
Regional anesthetic techniques, such as epidural catheter placement, might be particularly useful for opioid-tolerant patients because they cut down on the need for post-op opioids and may provide better long-term pain relief, notes Dr. Wu. Epidural anesthesia might have other benefits, as well, such as an earlier return of GI function. (See "6 Tips for Better Blocks" on page 35.)
Be aggressive in the PACU
Ideally, pre-op and intraoperative measures will create a steady-state level of opioids in the patient that will prevent pain altogether, or at least keep it at an acceptable level. However, if patients wake up in pain despite all precautions, it's important to treat them aggressively. Some tips:
Monitor patients closely
Don't release patients until they and their caregivers know exactly how to combat pain at home, experts say. Dr. Wu's patients, for example, usually take a sustained-release preparation of opioid or transdermal fentanyl to provide basal analgesia, as well as a short-acting PRN dose, such as morphine immediate-release, oxycodone or hydromorphone, for additional or breakthrough pain. Dr. Swenson notes that it may be advisable to make more than one follow-up call to ensure that patients are getting adequate pain relief at home and are following post-op instructions.
Tolerance vs. addiction
Finally, don't confuse tolerance with addiction, which is a psychological craving for opioids. Some healthcare providers are reluctant to administer high dosages for fear of creating or fostering an addiction. But most experts agree that if patients have no history of addiction, the chances of developing one in the healthcare setting is very low.
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