Will a patient's current chronic pain medication be sufficient to manage pain associated with an upcoming surgery?

Chronic Pain Medications Will Not Adequately Cover Surgical Pain

Patients on chronic pain medications will require additional pain management for surgical procedures, as their baseline analgesics are not sufficient to cover acute surgical pain.

Why Chronic Pain Medications Are Insufficient for Surgical Pain

Chronic pain medications are not designed to manage the intense acute pain associated with surgery for several key reasons:

1. Different Pain Mechanisms: Surgical pain involves acute tissue trauma, inflammation, and nociceptive stimulation that is more intense than the pain typically managed by chronic pain regimens 1.

2. Opioid Tolerance: Patients on long-term opioids develop tolerance, requiring higher doses for the same analgesic effect. This tolerance makes these patients more difficult to manage during the perioperative period 2.

3. Opioid-Induced Hyperalgesia: Chronic opioid use can lead to increased pain sensitivity (hyperalgesia), which may develop in as little as 4 weeks of therapy 1.

Recommended Approach for Perioperative Pain Management

Pre-Surgical Planning

• Maintain Baseline Medications: Continue the patient's chronic pain medications throughout the perioperative period to prevent withdrawal 2.

• Multimodal Analgesia Plan: Implement a comprehensive approach including:

  • Scheduled acetaminophen and NSAIDs as foundation (not just PRN) 2
  • Regional anesthesia techniques when anatomically feasible 2
  • Appropriate opioid dosing for breakthrough pain

Intraoperative Management

• Regional Anesthesia: Consider nerve blocks or neuraxial anesthesia appropriate to the surgical site 1, 2.

• Adjuvant Medications:

  • Single-dose IV dexamethasone (8 mg in adults) for anti-inflammatory and antiemetic effects 1
  • Consider low-dose ketamine (0.5 mg/kg/h maximum after induction) for patients with chronic pain or opioid tolerance 1, 2

Postoperative Management

• Continuous Regional Techniques: When appropriate, use perineural catheters for 48-72 hours postoperatively 2.

• Scheduled Non-Opioid Analgesics:

  • Regular acetaminophen (up to 4g/day)
  • NSAIDs if not contraindicated (avoid in patients on anticoagulants) 1

• Supplemental Opioids: Use immediate-release opioids for breakthrough pain, with dosing adjusted based on:

  • Age (reduce by 20-25% per decade after age 55) 2
  • Prior opioid exposure (higher doses likely needed)
  • Surgical procedure type and extent

Common Pitfalls to Avoid

1. Relying solely on pre-existing pain medications: This approach will lead to inadequate pain control and potentially increased complications 3.

2. Reactive rather than preventive pain management: Waiting until pain is severe before treating it leads to increased opioid requirements and poorer outcomes 2.

3. Focusing only on pain scores: Pain management should prioritize functional recovery rather than complete pain elimination 2.

4. Inappropriate use of gabapentinoids: Despite earlier enthusiasm, recent evidence does not support routine use of gabapentinoids for acute postoperative pain, particularly in older patients undergoing major surgery 2, 4.

Special Considerations for Chronic Opioid Users

• Patients with pre-existing pain conditions and those taking long-term opioids are particularly vulnerable to poorly controlled postoperative pain 1, 2.

• These patients may benefit from:

  • Preoperative pain specialist consultation
  • Higher doses of analgesics
  • More aggressive regional anesthesia techniques
  • Addition of ketamine as an adjunct (0.125-0.25 mg/kg/h) 1, 2

By implementing a comprehensive, proactive approach to perioperative pain management that goes beyond the patient's chronic pain regimen, you can better control surgical pain, improve outcomes, and potentially reduce the risk of developing persistent postsurgical pain.