Perioperative Management of Patients w OUD

Question 1

What are the four concerns in the management of SUD patient?

Answer 1

• Patient’s fear of inadequate pain management
• Patient’s fear of withdrawal
• Return to active use (relapse)
• Stigma adversely affecting interactions with medical providers and care received

Question 2

True or False: Patients with opioid use disorder, whether or not on medication for OUD, have lower pain thresholds than patients without OUD or opiate free recovering individuals?

Answer 2

True, have an increased sensitivity to pain and noxious stimuli

Question 3

Do methadone-maintained women have increased pain and will they require more oxycodone after cesarean delivery?

Answer 3

Yes, they have a diminished pain threshold and have increased sensitivity to pain and noxious stimuli

Question 4

True or False: Use of opioids increases the risk of relapse in patients with OUD

Answer 4

False: use of opioids do not add to the risk of relapse

Question 5

What substances have higher risk for seizures or CV hypersensitivity in inadequate withdrawal?

Answer 5

• Benzo’s
• ETOH

Question 6

What are some factors contributing to it being more difficult to manage patients with OUD in the hospital setting?

Answer 6

• Patient receives inadequate attention
• Patient unable to access usual coping mechanisms (social supports, able to move about freely, ability to smoke)

Question 7

What should be included in the preoperative evaluation of the patient with OUD?

Answer 7

• Hx and PE including a pain history
• Urine toxicology
• PDMP review
• ETOH use/disorder

Question 8

What are the challenges with medication for treatment of SUD in surgery?

Answer 8

• Adequacy of pain management
• Efficacy of anesthesia
• Prevention of return to active use (relapse)

Question 9

What is the preoperative management of methadone?

Answer 9

• Verify methadone dose with OTP
• Continue usual methadone dose on the day of surgery

Question 10

In the peri/intraoperative period should opioid/sedatives be continued and titrated to effect?

Answer 10

Yes

Be mindful that benzodiazepines will exacerbate respiratory distress

Question 11

Pain should be treated aggressively with conventional analgesics postoperatively, what is the typical dose for a patient with OUD?

What modes of dosing can be utilized?

Answer 11

Typically 1.5x higher than standard dose

Intermittent dosing or PCA

Question 12

What are some disadvantages for stopping buprenorphine prior to surgery?

Answer 12

• Difficult to restart
• Requires moderate withdrawal from full agonists before restarting buprenorphine
• Precipitatede withdrawal
• Increase riskof return to use

Question 13

Does the PAIN Clinical Practice Advisory recommend continuing buprenorphine during surgery?

Answer 13

Yes, but if not able to acheive appropriate analagesia can decrease dose

Question 14

What adjunct analgesia can be prescribed to maintain pain in the post-operative period for patients with OUD?

Answer 14

• NSAIDs
• Acetaminophen
• Gabapentionoids
• Ketamine
• Lidocaine
• Regional, local, and nerve blocks

Question 15

When is it appropriate to initiate opioid pain management?

What are the prefered opioids?

Answer 15

Once adjunct pain management measures have been implemented

In order: Fentanyl, Hydromorphone, Morphine