What is the recommended protocol for holding pain medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and opioids (such as oxycodone (oxycodone) or hydrocodone (hydrocodone)), before a preoperative exam?

Preoperative Management of Pain Medications

Most pain medications, including opioids (oxycodone, hydrocodone), should be continued through the morning of surgery with a small sip of water, while NSAIDs and acetaminophen can also be continued or even administered preoperatively as part of multimodal analgesia. 1, 2

Opioid Agonists (Oxycodone, Hydrocodone, etc.)

Continue on the morning of operation 1, 2

• Patients on long-term opioid therapy should take their normal morning dose on the day of surgery to prevent withdrawal symptoms and maintain baseline pain control 1
• Discontinuing opioids preoperatively can lead to rebound pain, withdrawal symptoms, and poor perioperative pain control 2
• Opioid-tolerant patients will require higher than usual opioid dosing postoperatively or need adjunctive nonopioid analgesia to achieve adequate pain control 1
• The small amount of water needed to take these medications (a sip) is permitted up to 2 hours before surgery and does not violate NPO status 2

Critical Considerations for Specific Opioids

• Codeine and tramadol are prodrugs requiring CYP2D6 metabolism; avoid combining with CYP2D6 inhibitors perioperatively as this reduces analgesic efficacy 1
• Meperidine should be avoided in renal insufficiency (GFR <30 mL/min/1.73 m²) due to toxic metabolite accumulation 1
• Fentanyl, methadone, levorphanol, tapentadol, and tramadol have serotonergic activity and increase risk of serotonin syndrome when combined with SSRIs, SNRIs, MAO inhibitors, or ondansetron 1

NSAIDs

Can be continued or held 1-10 days preoperatively depending on the specific agent and bleeding risk 3

Timing for Discontinuation by Agent (if holding is necessary):

• 1 day before surgery: Diclofenac, Ibuprofen, Ketorolac 3
• 2 days before surgery: Etodolac, Indomethacin 3
• 4 days before surgery: Meloxicam, Naproxen, Nabumetone 3
• 6 days before surgery: Oxaprozin 3
• 10 days before surgery: Piroxicam 3

When to Continue NSAIDs:

• NSAIDs can be administered preoperatively as part of multimodal analgesia to reduce opioid requirements and improve pain control 1
• Do not combine NSAIDs with curative doses of anticoagulants (enoxaparin, rivaroxaban, warfarin) as this multiplies bleeding risk by 2.5-fold 1
• NSAIDs combined with dexamethasone do not increase hemorrhage risk based on meta-analysis of 1,693 patients 1

Acetaminophen (Paracetamol)

Continue and take preoperatively, including on the day of surgery 1

• Acetaminophen should be administered at the beginning of postoperative analgesia as it may be safer than other analgesics 1
• Preoperative acetaminophen reduces opioid consumption and improves postoperative outcomes when used in multimodal therapy 1
• Can be taken with a small sip of water on the morning of surgery without violating NPO status 2

Special Medication Considerations

Buprenorphine (Suboxone, Subutex)

Individualize decision based on dose, indication, and expected postoperative pain 1

• For patients on ≤12 mg sublingual daily: Continue perioperatively 1
• For patients on >12 mg daily: Taper to 12 mg 2-3 days before surgery 1
• Buprenorphine blocks full mu-agonist opioids at doses >10 mg daily, requiring higher opioid doses for breakthrough pain 1
• Stopping buprenorphine abruptly increases relapse risk in patients with opioid use disorder 1

Butalbital (Combination Products)

Hold on day of surgery, but do not stop abruptly if used long-term 1

• If time allows, wean over 2 weeks to avoid acute withdrawal 1
• If insufficient time for weaning, continue perioperatively to prevent withdrawal symptoms 1
• Has additive effects with anesthetics causing hypotension, profound sedation, and potential death 1

Ergotamine

Hold at least 2 days prior to operation 1, 2

• Ergotamine inhibits norepinephrine reuptake and acts as serotonergic agonist 1
• Combining with anesthetics may exacerbate peripheral vasoconstriction and increase serotonin syndrome risk 1

Naltrexone

Hold intramuscular naltrexone 24-30 days after last injection; hold oral naltrexone 3-4 days preoperatively 1

Multimodal Preoperative Analgesia Strategy

Administer a combination of acetaminophen, NSAIDs (if not contraindicated), and continue baseline opioids to optimize perioperative pain control 1

• Timing of preoperative analgesics should achieve optimal pharmacodynamic effect coinciding with surgery onset 1
• This multimodal approach reduces individual drug-related side effects and decreases opioid requirements 1
• All medications should be age and dose-adjusted, particularly in elderly patients and those with renal dysfunction 1

Critical Pitfalls to Avoid

• Never abruptly discontinue long-term opioids before surgery as this causes withdrawal, rebound pain, and poor postoperative outcomes 1, 2
• Avoid combining NSAIDs with therapeutic anticoagulation due to multiplicative bleeding risk 1
• Do not use meperidine, codeine, or morphine in renal insufficiency due to toxic metabolite accumulation 1
• Be vigilant for serotonin syndrome when using serotonergic opioids (fentanyl, methadone, tramadol, tapentadol) with SSRIs, SNRIs, or ondansetron 1
• Adjust gabapentinoid doses in elderly and renally impaired patients to avoid excessive sedation 1