How does the opioid crisis impact anesthesiologists in managing pain for patients, particularly those with a history of substance abuse or mental health disorders?

Impact of the Opioid Crisis on Anesthesiologists

Anesthesiologists must fundamentally shift from opioid-centric perioperative pain management to multimodal, opioid-sparing approaches while simultaneously becoming expert managers of patients with opioid use disorder (OUD) who require surgery. 1, 2

Core Clinical Responsibilities Created by the Crisis

1. Rational Opioid Prescribing Framework

Anesthesiologists must apply Maxwell's rational-prescribing approach to every perioperative case, which requires: 1

• Diagnosing pain mechanisms by evaluating patient symptoms, targetable pain pathways, complete medication history including substance use disorders, and planned procedure characteristics 1
• Optimizing preoperative conditions by weaning opioids when appropriate and addressing psychological risk factors (anxiety, depression, catastrophic thinking) that correlate with greater postoperative opioid requirements 1
• Establishing realistic pain goals through shared decision-making rather than promising complete pain elimination—one study showed patients who selected their own opioid quantities chose half the usual prescribed amount yet maintained 90% satisfaction 1

2. Managing Patients on Medications for OUD (MOUD)

Continue all maintenance therapy (methadone or buprenorphine) throughout the perioperative period without interruption. 3, 2 This is non-negotiable because:

• Mortality risk increases 3.2-fold when patients discontinue methadone treatment, with the four weeks after cessation showing mortality exceeding 30 deaths per 1000 person-years 4
• Maintenance doses do not provide adequate analgesia for acute pain—this is the most dangerous misconception 5

For patients on methadone: 3

• Verify and continue the maintenance dose
• Split daily methadone into 6-8 hour intervals to leverage its shorter analgesic duration (versus 24-hour withdrawal prevention)
• Add short-acting opioids using scheduled dosing at higher doses and shorter intervals than for opioid-naïve patients
• Monitor level of consciousness and respiration frequently when adding opioids to methadone therapy 3

For patients on buprenorphine (Suboxone): 5

• Continue the usual buprenorphine dose perioperatively
• Add ketamine as an opioid-sparing analgesic (bolus <0.35 mg/kg IV; infusion 0.5-1 mg/kg/h maximum) since it works via NMDA receptor antagonism independent of mu-opioid receptors 5
• Avoid ketamine only in uncontrolled cardiovascular disease, pregnancy, active psychosis, severe liver dysfunction, high intracranial pressure, or elevated ocular pressure 5

3. Understanding Pain Facilitation in OUD Patients

Patients with OUD have a "syndrome of pain facilitation" where their pain experience is objectively worse than opioid-naïve patients. 3, 4 This occurs through:

• Subtle withdrawal syndromes, intoxication, withdrawal-related sympathetic arousal, sleep disturbances, and affective changes 3
• Latent hyperalgesia from long-term opioid exposure involving neuroplastic changes with NMDA receptors 4
• Lower pain tolerance than peers in remission 3

Critical principle: Never allow pain to reemerge before administering the next dose, as this causes unnecessary suffering and increases tension between patient and treatment team 3

4. Implementing Multimodal Opioid-Sparing Analgesia

Start with aggressive non-opioid interventions as first-line therapy: 3, 6

• Basic multimodal foundation (start preoperatively or intraoperatively): paracetamol, COX-2 inhibitor or conventional NSAID, dexamethasone, and local anesthetic wound infiltration 6
• Regional anesthesia techniques: nerve blocks or interfascial plane blocks when anatomically appropriate 6
• Adjuvant analgesics: gabapentinoids (though caution in older adults due to dizziness and visual disturbance without significant pain benefit), clonidine, intravenous lidocaine infusion, or ketamine infusion 1, 6
• Neuraxial analgesia during labor should be encouraged for obstetric patients with OUD 1

Evidence for opioid-free anesthesia (OFA): High-quality meta-analysis by Olausson showed OFA associated with significantly lower postoperative opioid consumption and fewer adverse events, though impact on persistent postoperative opioid use (PPOU) remains unclear 1

5. Avoiding Critical Pitfalls

Never use mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) in patients on methadone or buprenorphine, as these precipitate acute withdrawal syndrome 3, 4

Avoid long-acting opioid formulations (modified-release oral and transdermal) for postoperative pain, as slow onset times make safe titration impossible and increase opioid-induced ventilatory impairment (OIVI) risk 1

Do not rely solely on unidimensional pain scores to guide opioid titration—this increases OIVI risk. Instead, assess patient function and use sedation scoring systems 1, 7

Implement mandatory sedation scoring for all patients receiving opioids, using a system without an 'S' (sleeping) category that allows proper assessment. Target sedation scores <2 to prevent OIVI 1

Avoid "opiophobia"—the exaggerated tendency to undermedicate due to unfounded fears. Undertreating pain decreases responsiveness to opioid analgesics and makes subsequent control more difficult 3

6. Discharge Prescribing Practices

For opioid-naïve patients after routine vaginal delivery: 1

• First-line: NSAIDs and acetaminophen (unless contraindicated)
• Consider short course of low-dose opioids only for severe pain unresponsive to non-opioids
• Severe pain after vaginal delivery is unusual and should prompt evaluation for complications 1

For opioid-naïve patients after cesarean delivery: 1

• First-line: NSAIDs and acetaminophen
• Add opioids only if pain persists
• On discharge, prescribe limited number of opioid pills with counseling about benefits, risks, side effects, and misuse potential 1

Prescribe naloxone to all patients with substance use disorder history due to increased overdose risk 3

7. Special Considerations for Delirium Prevention

Balance adequate analgesia against opioid-related delirium risk in older adults: 1

• Uncontrolled pain increases delirium risk 9-fold in hip fracture patients 1
• However, opioid side effects (sedation, hallucination) can precipitate or mimic delirium 1
• Titrate opioids to minimal effective dose rather than avoiding them entirely—studies show patients receiving <10mg morphine equivalents daily had 5.4-fold increased delirium risk compared to those receiving >10mg 1
• Avoid pethidine; morphine, fentanyl, and oxycodone are not specifically associated with delirium when properly titrated 1
• Use multimodal pain management preferentially, including routine paracetamol, NSAIDs when appropriate, and local anesthetic blocks 1

8. Organizational Leadership Role

Anesthesiologists must lead perioperative teams in implementing opioid stewardship programs: 2, 7

• Develop standardized order sets linking opioid prescriptions to monitoring protocols 1
• Create multidisciplinary care models involving addiction specialists, behavioral health specialists, and palliative care specialists 3
• Establish clear treatment agreements documenting pill dispensing, frequency of use, and expected duration 3
• Evaluate benefits and harms within 1-4 weeks of any dose change 3

The solution to reducing perioperative neurocognitive disorders and opioid-related harm is not in anesthesiologists' hands alone, but we are key members of the multidisciplinary perioperative team and well-placed to lead organizational initiatives. 1