What are the options for postoperative pain control in patients with chronic narcotic (opioid) use?

From the Guidelines

Managing postoperative pain in patients on chronic narcotics requires a multimodal approach with higher opioid doses than typical patients, and the most recent evidence suggests continuing their baseline opioid regimen and adding additional short-acting opioids for breakthrough pain, typically at 25-50% higher doses than opioid-naive patients 1. For these patients, a combination of non-opioid analgesics such as scheduled acetaminophen (1000mg every 6 hours, not exceeding 4000mg daily) and NSAIDs like ibuprofen (600mg every 6 hours) can be effective in reducing opioid requirements. Adjuvants like gabapentin (300mg three times daily) or pregabalin (75mg twice daily) can also be beneficial in managing postoperative pain. Some key points to consider in postoperative pain management for patients on chronic narcotics include:

• Using a multimodal approach to analgesia, including non-opioid analgesics and adjuvants, to reduce opioid requirements and minimize side effects 1
• Continuing the patient's baseline opioid regimen and adding additional short-acting opioids for breakthrough pain, typically at 25-50% higher doses than opioid-naive patients 1
• Considering regional anesthesia techniques, when appropriate for the surgical site, to significantly reduce opioid requirements
• Using patient-controlled analgesia (PCA) pumps in the immediate postoperative period to manage pain effectively
• Monitoring closely for respiratory depression, despite tolerance to opioid side effects, and being aware of the potential for opioid-induced hyperalgesia, which can make pain management more challenging 1.

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 Although it is not possible to list every condition that is important to the selection of the initial dose of oxycodone hydrochloride tablets, attention should be given to: 1) the daily dose, potency, and characteristics of a pure full agonist or mixed agonist/antagonist the patient has been taking previously, 2) the reliability of the relative potency estimate to calculate the dose of oxycodone needed, 3) the degree of opioid tolerance, 4) the general condition and medical status of the patient, and 5) the balance between pain control and adverse experiences. Conversion from Other Opioids to Oxycodone Hydrochloride Tablets There is inter-patient variability in the potency of opioid drugs and opioid formulations Therefore, a conservative approach is advised when determining the total daily dosage of oxycodone hydrochloride tablets.

The options for postoperative pain control in patients with chronic narcotic (opioid) use include:

• Individualized dosing: 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.
• Conversion from other opioids: Conversion from other opioids to oxycodone hydrochloride tablets, with close observation and adjustment of dosage based upon the patient’s response to oxycodone hydrochloride tablets.
• Titration of dosage: Titration of the total daily dose of oxycodone hydrochloride tablets may be necessary, especially in patients who have disease states that are changing rapidly. 2

From the Research

Postoperative Pain Control Options

The following options are available for postoperative pain control in patients with chronic narcotic (opioid) use:

• Multimodal analgesia, which involves the use of a combination of opioid and non-opioid analgesic drugs to minimize opioid use and decrease opioid-related side effects 3, 4, 5
• Intravenous non-opioid analgesia, such as intravenous acetaminophen and ibuprofen, which have been shown to be effective in reducing opioid consumption and improving pain control 4
• Nonopioid analgesics, such as NSAIDs, glucocorticoids, and gabapentinoids, which can be used alone or in combination to enhance pain relief and reduce opioid requirements 6, 7
• Prescribing a different opioid after surgery, which has been shown to reduce medication requirements for patients taking opioids prior to surgery 6

Benefits of Multimodal Analgesia

Multimodal analgesia has been shown to:

• Improve pain control after surgery 3, 4, 5
• Reduce opioid consumption and opioid-related side effects 3, 4, 5
• Enhance patient satisfaction with pain control 4, 6

Considerations for Patients with Chronic Opioid Use

Patients with chronic opioid use may require special consideration when it comes to postoperative pain control, as they may:

• Use more opioid pills after surgery 6
• Seek more pills after surgery 6
• Be less satisfied with their pain control 6
• Require additional strategies to address postoperative pain management 6