perioperative management of pt with OUD

Question 1

do patients with an opioid use disorder have a lower or higher pain threshold

Answer 1

lower

Question 3

What is OAT

Answer 3

opioid agonist therapy

Question 4

what are the pharmacodynamics of Methadone/buprenorphine

Answer 4

analgesic properties are MUCH shorter than their suppression of opiate withdrawal

Question 5

what is neuroplastic changes that occur with chronic administration of opiates that produce significant diminutiionof the analgesic properties of the maintenance agonists

Answer 5

tolerance

Question 6

what are the challenges with medication for treatment of SUD in surgery

Answer 6

adequacy of pain management
efficacy of anesthesia
prevention of return to active use (relapse)

Question 7

what is the preoperative management of methadone

Answer 7

verify methadone dose with OTP
continue usual methadone dose on the day of surgery

Question 8

what is the peri/intraoperative management of methadone

Answer 8

titrate pre- and intra-operative opioids/sedatives to effect - mindful that benzos will exacerbate RD
multimodal anesthesia techniques - local, regional, nerve blocks

Question 9

what is the post operative managment of methadone

Answer 9

continue usual verified methadone dose (divided vs single dose)
treat pain aggressively with conventional analgesiscs
avoid using mixed agonists/antagonist opioids as they precipitate acute withdrawal
careful use and monitoring of combination products containing acetaminophen and NSAIDs

Question 10

what are the advantages of maintaining buprenorphine

Answer 10

no interruption in treatment
decreased risk of destabilization of OUD
obviates need to restart partial agonists in face of full agonists

Question 11

what are the disadvantages of bupenorphine discontinuation

Answer 11

difficult to restart buprenorphine
- requires moderate withdrawal from full agonists before restartng buprenorphine
- precipitated w/d
- increased risk of return to use

Question 12

what are appropriate adjunct analgesics that can be used in the post operative period

Answer 12

• NSAIDS
• acetaminophen
• gabapentinoids
• ketamine
• lidocaine
• regional, local and nerve blockade anesethesia

Question 13

what are full agonists options that can be used for post operative pain management

Answer 13

fentanyl
morphine
hydromorphone

Question 14

what is the management of Naltrexone

Answer 14

will blockade opioid pain/analgesic drugs
ideally stop pre-op: oral d/c 5-7 days, parenteral do not give next dose prior to surgery, schedule surgery 5-7 days following cancelled dose