What is the most appropriate counseling for a patient receiving methadone (opioid agonist) for opioid use disorder (OUD) during preoperative evaluation for an elective procedure?

Perioperative Management of Methadone for Opioid Use Disorder

For patients receiving methadone for opioid use disorder, the most appropriate preoperative counseling is to continue their usual methadone maintenance dose throughout the perioperative period, including on the morning of surgery. 1

Rationale for Continuing Methadone

Continuing methadone maintenance therapy during the perioperative period is crucial for several reasons:

1. Prevention of withdrawal: Discontinuing methadone can precipitate withdrawal symptoms, which can complicate perioperative management and increase patient distress 2

2. Relapse prevention: Interrupting methadone therapy increases the risk of relapse to illicit opioid use 3

3. Pain management: Methadone's long half-life (8-59 hours) provides a baseline level of analgesia, though it will not be sufficient for surgical pain 2

Key Perioperative Counseling Points

Preoperative Period

• Verify the dose: Contact the patient's methadone maintenance clinic or prescribing physician to verify the current methadone dose 1
• Take morning dose: Instruct the patient to take their usual methadone dose on the morning of surgery 1
• Reassurance: Explicitly reassure the patient that their addiction history will not prevent adequate pain management 1
• Medication reconciliation: Review all medications for potential interactions with anesthetics or analgesics 1

Intraoperative Considerations

• Inform the anesthesiologist about the patient's methadone maintenance therapy
• Patients on methadone will likely require higher doses of intraoperative anesthetics due to cross-tolerance 1
• Avoid mixed agonist-antagonist opioids (like butorphanol, nalbuphine) as they may precipitate withdrawal 1

Postoperative Pain Management

• Higher opioid requirements: Patients will require higher doses of short-acting opioids at shorter intervals due to opioid cross-tolerance 1
• Scheduled dosing: Use continuous scheduled dosing rather than as-needed (PRN) orders 1
• Multimodal analgesia: Utilize non-opioid analgesics (NSAIDs, acetaminophen, etc.) to minimize opioid requirements 1
• Communication: Notify the patient's methadone maintenance program about any additional opioids prescribed during hospitalization 1

Common Pitfalls to Avoid

1. Discontinuing methadone: Never discontinue methadone maintenance therapy before surgery, as this can lead to withdrawal and increased risk of relapse 1, 3

2. Inadequate pain control: Assuming the maintenance dose of methadone will provide sufficient analgesia for surgical pain 1

3. Using mixed agonist-antagonist opioids: These can precipitate withdrawal in patients on methadone 1

4. Stigmatization: Allowing bias against patients with OUD to affect pain management decisions 1

5. Discharge planning: Failing to coordinate with the patient's methadone maintenance program about discharge medications and follow-up 1

Discharge Planning

• Coordinate with the patient's methadone maintenance program regarding discharge and any opioid medications prescribed 1
• Provide clear instructions on resuming regular methadone dosing schedule
• Ensure the patient has appropriate follow-up with both surgical team and addiction treatment providers 1
• Consider providing naloxone kit if additional opioids are prescribed for postoperative pain 4

By following these guidelines, healthcare providers can effectively manage perioperative pain while maintaining the patient's opioid use disorder treatment, minimizing the risk of withdrawal, relapse, and inadequate pain control.