Should a patient's postoperative pain management regimen include the same opioids they are currently taking for pain management or different ones?

Postoperative Pain Management for Patients on Chronic Opioids

For patients already on chronic opioid therapy, postoperative pain management should continue the same opioids they were taking preoperatively, while adding short-acting opioids as needed for breakthrough pain. 1

Preoperative Assessment and Planning

Evaluation of Current Opioid Regimen

• Calculate the oral morphine equivalent (OME) of the patient's current regimen
• Identify specific opioids and formulations the patient is taking
• Assess for opioid tolerance (likely at OME doses of 60 mg/day for 7 days or more) 1

Perioperative Management Plan

1. Continue baseline opioids: Patients on chronic opioid therapy should continue their usual opioids throughout the surgical admission 1
2. Create individualized plan: For patients on specific medications like buprenorphine or methadone, develop a tailored perioperative plan 1
3. Consult specialists: For patients on high opioid doses, obtain pain specialist consultation before surgery 1

Intraoperative Considerations

• Implement multimodal analgesia techniques (regional anesthesia, NSAIDs, acetaminophen) to minimize additional opioid requirements 1
• Anticipate higher opioid requirements for adequate analgesia in opioid-tolerant patients 1
• For patients on buprenorphine specifically, evidence suggests continuing it perioperatively is appropriate 2

Postoperative Pain Management

Immediate Postoperative Period

• Continue the patient's baseline opioid regimen to prevent withdrawal 1
• Add short-acting opioids for breakthrough pain, recognizing that higher doses may be required 1
• For patients unable to take oral medications, convert to parenteral equivalents (preferably morphine) 1

Specific Recommendations for Buprenorphine

• For patients on buprenorphine, continuing their usual dose is recommended rather than discontinuing it 1, 2
• Research shows patients who received their usual buprenorphine dose postoperatively required significantly less additional opioid analgesia compared to those who did not receive their dose 2

Multimodal Approach

• Utilize non-opioid analgesics (acetaminophen, NSAIDs if not contraindicated)
• Consider adjuvant medications (gabapentinoids, ketamine) when appropriate
• Implement regional anesthesia techniques when feasible 1

Discharge Planning

• Continue the patient's baseline chronic opioid regimen 1
• Provide short-acting opioids for breakthrough pain only if needed, typically for 5-7 days maximum 1
• Clearly document in the discharge letter:
  • The patient's baseline opioid regimen
  • Any additional opioids prescribed for acute pain
  • Duration of additional opioid therapy (typically 5-7 days) 1
• Coordinate with the patient's pain management provider for ongoing care 1

Monitoring and Follow-up

• Involve the inpatient pain service in the care of opioid-tolerant patients 1
• Arrange follow-up with the patient's pain management provider
• Consider referral to transitional pain services for complex cases 3
• Monitor for signs of inadequate pain control or adverse effects

Common Pitfalls to Avoid

1. Discontinuing baseline opioids: This can lead to withdrawal and worsened pain control 1
2. Underdosing: Opioid-tolerant patients often require higher doses of opioids for adequate analgesia 1
3. Overreliance on opioids: Failing to implement multimodal analgesia can lead to excessive opioid use 1
4. Poor coordination: Lack of communication between surgical team and pain management provider can lead to suboptimal care 1
5. Inappropriate discharge planning: Failing to provide clear instructions on opioid management after discharge 1

By continuing the patient's baseline opioid regimen and adding appropriate short-acting opioids for breakthrough pain, while implementing multimodal analgesia techniques, optimal postoperative pain control can be achieved while minimizing complications related to opioid therapy.