How to manage postoperative pain in patients on opioids (opioid analgesics) after surgery?

From the Guidelines

Managing postoperative pain in patients on opioids requires a patient-centered, multimodal approach that prioritizes functional outcomes over unidimensional pain scores, as recommended by the most recent consensus statement 1. To achieve this, consider the following strategies:

• Continue the patient's baseline opioid regimen and add additional opioids for breakthrough pain, typically at doses 25-50% higher than opioid-naïve patients, while monitoring for opioid-induced ventilatory impairment 1.
• Implement scheduled non-opioid analgesics, such as acetaminophen (1000mg every 6 hours, not exceeding 4g daily) and NSAIDs like ketorolac (15-30mg IV every 6 hours for 48-72 hours) or ibuprofen (600mg every 6 hours), to reduce opioid requirements.
• Utilize regional anesthesia techniques, such as nerve blocks or epidural analgesia, to significantly reduce opioid needs.
• Consider adjuvant medications like gabapentin (300-600mg three times daily), pregabalin (75-150mg twice daily), or ketamine infusions (0.1-0.2mg/kg/hr) to manage pain through different pathways.
• Patient-controlled analgesia (PCA) with appropriate lockout intervals and higher basal rates may be beneficial in the immediate postoperative period.
• For patients on buprenorphine, continue buprenorphine therapy in the perioperative period, as recommended by the expert consensus Delphi-based survey technique 1, and initiate a full mu agonist if analgesia is inadequate after optimizing adjunct analgesic therapies. It is essential to monitor these patients more frequently for pain scores, sedation levels, and respiratory status, as they are at higher risk for both inadequate pain control and respiratory depression.

From the FDA Drug Label

Initiate the dosing regimen for each patient individually, taking into account the patient's severity of pain, patient response, prior analgesic treatment experience, and risk factors for addiction, abuse, and misuse [see Warnings and Precautions (5. 1)] Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases with oxycodone hydrochloride tablets and adjust the dosage accordingly [see Warnings and Precautions (5.3)] Therefore, a conservative approach is advised when determining the total daily dosage of oxycodone hydrochloride tablets. It is safer to underestimate a patient’s 24-hour oxycodone hydrochloride tablets dosage than to overestimate the 24-hour oxycodone hydrochloride tablets dosage and manage an adverse reaction due to overdose If a patient has been receiving opioid-containing medications prior to taking oxycodone hydrochloride tablets, the potency of the prior opioid relative to oxycodone should be factored into the selection of the total daily dose (TDD) of oxycodone Individually titrate oxycodone hydrochloride tablets to a dose that provides adequate analgesia and minimizes adverse reactions

To manage postoperative pain in patients on opioids after surgery, initiate treatment with a low dose and titrate based on individual patient response. Consider the patient's:

• Severity of pain
• Prior analgesic treatment experience
• Risk factors for addiction, abuse, and misuse
• Opioid tolerance Monitor patients closely for respiratory depression, especially within the first 24 to 72 hours of initiating therapy and following dosage increases. Adjust the dosage accordingly to balance pain control and minimize adverse reactions 2 2. Use a conservative approach when determining the total daily dosage of oxycodone hydrochloride tablets to avoid overdose. Key considerations include:
• Prior opioid use: factor in the potency of the prior opioid relative to oxycodone
• Disease states: consider changing disease states that may affect pain levels and opioid requirements
• Adverse reactions: continually reevaluate patients to assess the incidence of adverse reactions and adjust the dosage as needed.

From the Research

Managing Postoperative Pain in Patients on Opioids

To manage postoperative pain in patients on opioids, several strategies can be employed:

• Alternative medications: Alternative oral and intravenous medications, as well as novel intraoperative regional anesthetic techniques, can be used to reduce perioperative opioid use 3.
• Opioid-sparing sedative and analgesic strategies: Postoperative opioid-sparing sedative and analgesic strategies can be implemented to minimize opioid use 3.
• Assessing preoperative opioid use: Identifying preoperative opioid use can inform surgeon prescribing and care coordination for pain management after surgery 4.
• Nonopioid alternatives: Nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen can be used as nonopioid alternatives for acute pain management 5, 6.
• Combination therapy: Combination therapy using a small amount of opioid together with a nonopioid pain reliever can be effective and reduce opioid consumption 5.
• Tailored pharmacologic management: Pharmacologic management of acute pain should be tailored for each patient, including a review of treatment expectations and a plan for the time course of prescriptions 6.

Considerations for Opioid Use

When managing postoperative pain in patients on opioids, the following considerations should be taken into account:

• Risk of opioid diversion: Patients might consume less than half of the opioid pills they are prescribed, highlighting the need to standardize opioid prescriptions and reduce opioid diversion 7.
• Opioid epidemic: The opioid epidemic has increased physician and community awareness of the harms of opioid medications, and severe acute pain may necessitate short-term use of opioids with attention to minimizing risk 6.
• Patient satisfaction: Patients' satisfaction with their overall postoperative pain management should be assessed, and adjustments made as needed to ensure effective pain control 7.