Will a patient already on chronic opioid therapy require additional or higher‑dose opioids after surgery, and what is this phenomenon called?

Opioid Tolerance and Increased Postoperative Requirements

Yes, patients already on chronic opioid therapy will require additional or higher-dose opioids after surgery to achieve adequate pain control—this phenomenon is called opioid tolerance. 1

What is Opioid Tolerance?

Opioid tolerance is the physiological state where the body adapts to chronic opioid exposure, requiring increasing doses to maintain the same analgesic effect. 2 This develops through desensitization of mu opioid receptors after repeated agonist binding. 1

• Tolerance occurs to both desired (analgesia) and undesired effects of opioids 2
• It may develop at different rates for different effects 2
• Tolerance typically develops after several days to weeks of continued opioid usage 2

Clinical Impact on Surgical Patients

Patients on chronic opioid therapy face significantly worse postoperative outcomes:

• Higher pain scores and slower pain resolution compared to opioid-naïve patients 1
• Longer hospital stays with increased chance of readmission 1
• Up to 10 times higher risk of persistent postoperative opioid use compared to opioid-naïve patients 1
• 80% probability of persistent postoperative opioid use when taking ≥60 mg oral morphine equivalents daily preoperatively 1

Perioperative Management Strategy

Continue baseline opioids through surgery and expect to add supplemental doses:

Preoperative Phase

• Continue chronic opioids up to and including the morning of surgery 1
• Do not abruptly discontinue—this risks serious withdrawal symptoms, uncontrolled pain, and suicide 2
• If weaning is attempted, it must be individualized with shared decision-making to ensure pain remains controlled 1
• Optimize with multimodal non-opioid adjuncts where possible 1

Intraoperative and Postoperative Phase

• Plan for higher-than-usual opioid dosing to achieve pain control 1
• Alternatively, use adjunctive nonopioid analgesia perioperatively 1
• Patients will likely need 50-100% higher opioid doses than opioid-naïve patients for equivalent analgesia 1, 3
• Maximize multimodal analgesia (acetaminophen, NSAIDs, gabapentinoids, regional techniques) to reduce total opioid requirements 3, 4

Critical Pitfall to Avoid

Do not assume these patients are "drug-seeking" when they report inadequate pain control. 1 Opioid-tolerant patients have legitimate increased analgesic requirements due to receptor desensitization. Undertreating their pain leads to worse outcomes, prolonged recovery, and potential for uncontrolled pain driving aberrant behaviors. 1

Discharge Considerations

• Limit discharge opioid prescriptions to 5-7 days maximum 1, 3, 4
• Avoid automatic refills—any request for additional opioids should trigger patient review 1
• If patients remain on opioids at 90 days post-surgery, refer to pain specialists 1, 4
• Provide explicit instructions on dose, duration, and safe disposal of unused medications 1, 3

Key Risk Factor

Preoperative opioid use is the single strongest predictor of chronic postoperative opioid use and worse surgical outcomes. 1, 3 This dose-dependent relationship means higher preoperative doses (especially >30 morphine milligram equivalents) predict even worse outcomes including lower return-to-work rates, higher disability scores, and lower quality of life measures at 1-2 years post-surgery. 1, 3