Do chronic opioid (narcotic) pain medications alleviate pain from acute surgical procedures?

From the Guidelines

Chronic opioid pain medications are not sufficient to alleviate pain from acute surgical procedures and should be supplemented with short-acting opioids and non-opioid medications as part of a multimodal analgesia approach. This is because patients on long-term opioid therapy often develop tolerance, requiring additional medication for breakthrough pain during acute procedures 1. For example, a patient on daily morphine extended-release 30mg twice daily may need additional short-acting opioids like oxycodone 5-10mg every 4-6 hours as needed for acute procedural pain.

Key Considerations

• Chronic opioid use downregulates opioid receptors and activates compensatory pain pathways, making patients more sensitive to new pain stimuli 1.
• The steady-state blood levels maintained by long-acting opioids are designed for constant background pain, not the sudden intense pain of procedures 1.
• Non-opioid medications such as acetaminophen 1000mg every 6 hours and/or NSAIDs like ibuprofen 400-600mg every 6 hours should be used in conjunction with opioids to minimize opioid use and reduce the risk of adverse effects 1.
• Healthcare providers should anticipate the need for supplemental pain management and develop appropriate acute pain management plans for patients on chronic opioid therapy before procedures 1.

Recommendations

• Use a multimodal analgesia approach that includes short-acting opioids, non-opioid medications, and non-pharmacologic therapies to manage acute procedural pain in patients on chronic opioid therapy 1.
• Prescribe immediate-release opioids at the lowest effective dose and for no longer than the expected duration of pain severe enough to require opioids 1.
• Consider concurrent medical conditions, including sleep apnea, pregnancy, renal or hepatic insufficiency, mental health conditions, and substance use disorders, in assessing risks of opioid therapy 1.
• Offer naloxone, particularly if the patient or a household member has risk factors for opioid overdose, and use particular caution when prescribing benzodiazepines or other sedating medications with opioid pain medication 1.

From the FDA Drug Label

Fentanyl transdermal system is contraindicated: in patients who are not opioid-tolerant in the management of acute pain or in patients who require opioid analgesia for a short period of time in the management of post-operative pain, including use after out-patient or day surgeries Because serious or life-threatening hypoventilation could result, fentanyl transdermal system is contraindicated for use on an as needed basis (i.e., prn), for the management of post-operative or acute pain, or in patients who are not opioid-tolerant or who require opioid analgesia for a short period of time

Chronic opioid (narcotic) pain medications like fentanyl transdermal system are not indicated for alleviating pain from acute surgical procedures.

• The medication is contraindicated for the management of post-operative pain.
• It is also contraindicated for use in patients who require opioid analgesia for a short period of time.
• The use of fentanyl transdermal system is limited to patients who are opioid-tolerant and require continuous, around-the-clock opioid administration for an extended period of time 2, 2, 2.

From the Research

Chronic Opioid Pain Medications for Acute Surgical Procedures

• The use of chronic opioid pain medications for acute surgical procedures is a complex issue, with various studies suggesting alternative approaches to manage pain effectively 3, 4.
• According to a study published in the American Family Physician, acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first-line treatment options for most patients with acute mild to moderate pain 3.
• Another study published in the Journal of the American Medical Association (JAMA) Network Open found that ketamine is a viable alternative to opioids for out-of-hospital traumatic pain, with noninferiority for pain reduction 5.
• A review published in Expert Opinion on Pharmacotherapy suggests that NSAIDs and acetaminophen can effectively replace opioid treatment options for acute pain, although combination therapy using a small amount of opioid together with a nonopioid pain reliever may be effective in reducing opioid consumption 4.

Management of Acute Pain in Patients on Opioid Use Disorder Medications

• Managing acute pain in patients with opioid use disorder (OUD) on medication can be complicated, with higher baseline pain sensitivity and need for higher opioid doses to achieve pain relief 6, 7.
• A narrative review published in Current Pain and Headache Reports found that naltrexone can complicate postoperative pain management, and alternative modalities such as ketamine, lidocaine/bupivacaine, and non-pharmacological management can help manage pain in patients on naltrexone 6.
• A rapid review published in the Journal of General Internal Medicine found that continuing methadone or buprenorphine in OUD patients after surgery may reduce the need for additional opioids, but there is a lack of rigorous evidence on acute pain management in patients taking medication for OUD 7.

Alternative Approaches to Opioid Pain Medications

• Studies suggest that alternative approaches such as ketamine, NSAIDs, and acetaminophen can be effective in managing acute pain, reducing the need for opioid pain medications 5, 4.
• Multimodal pain regimens and non-pharmacological management can also help mitigate opioid dependence and manage pain in patients with acute surgical procedures 6.