Pain Management

Question 1

A 36-year-old with a history of opioid dependence is booked for spinal surgery. The patient is no longer on opioids and is maintained on 50mg of oral naltrexone daily.

Discuss the implications of the history of opioid dependence and current naltrexone treatment for the provision of effective
perioperative analgesia, including an analgesia plan upon hospital discharge.

Answer 1

Preop
Previous Opioid Dependence
- risk of relapse off naltrexone
- increased mortality as more sensitive to opioids
need extra supports community/inpatient admission when stopping naltrexone
May have concers/fears about receiving opioids
Need to involve GP/Addiction specialist with plan

NALTREXONE
competitive antagonist of all opioids
must be stopped 3 days prior otherwise inadaquate pain control, very high opioid requirement , difficult to manage hypertension with GA

Intraop

Surgery - determine if laminectomy vs instrumentation (more painful)

D/W Surgeon - epidural for post operative analgesia where possible

Multimodal analgesia - Paracetamol, NSAIDs (once surgeon happy), low dose ketamine infusion @ 4mg/hr

POST OP
May be increased sensitivity to opioids - increased apnoea risk - consider HDU if no epidural and requires PCA

Aim for atypical opioids / mutigesics eg Tapentadol - but more not be possible as painful operation

DIscharge
Involve GP/Addiction Specialist
Aim to wean opioids ASAP
Restart Naltrexone 5 DAYS after last opioid dose.