Difference between revisions of "Opioid use disorder"

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{{Infobox comorbidity
{{Infobox comorbidity
| anesthetic_relevance = High
| anesthetic_relevance = High
| anesthetic_management =  
| anesthetic_management = Use non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonist opioid analgesics (e.g. fentanyl, hydromorphone)
| specialty = Pain
| specialty = Pain
| signs_symptoms =
| diagnosis =
| treatment =
| image =  
| image =  
| caption =  
| caption =  
}}
}}


Provide a brief summary of this comorbidity here.
This article focuses primarily on management considerations for patients on Suboxone therapy.  


== Epidemiology ==
== Epidemiology ==


== Anesthetic implications ==
== Anesthetic implications ==
Patient's with opioid use disorder on maintenance therapy with Suboxone (buprenorphine-naloxone) or methadone are at high risk of inadequately controlled pain post-procedure 2/2 low dosing or slow titration.  
Patient's with opioid use disorder on maintenance therapy with Suboxone (buprenorphine-naloxone) or methadone are at high risk of inadequately controlled pain post-procedure due to low dosing or slow titration.


== Pathophysiology ==
== Pathophysiology ==
Buprenorphine is a partial mu-opioid receptor agonist and kappa-opioid receptor. It is associated with less opioid-induced hyperalgesia compared to other opioids.  
Buprenorphine is a partial mu-opioid receptor agonist and kappa-opioid receptor. It is unique in that its action at the mu-opioid receptor can block binding of other opioids.  


== Anesthetic management ==
== Anesthetic management ==


=== Preoperative optimization ===
=== Preoperative optimization ===
The dose of suboxone has implications for the risk of opioid tolerance and increased post-operative pain.  
Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy<ref>{{Cite journal|last=Alford|first=Daniel P.|last2=Compton|first2=Peggy|last3=Samet|first3=Jeffrey H.|date=2006-01-17|title=Acute pain management for patients receiving maintenance methadone or buprenorphine therapy|url=https://pubmed.ncbi.nlm.nih.gov/16418412/|journal=Annals of Internal Medicine|volume=144|issue=2|pages=127–134|doi=10.7326/0003-4819-144-2-200601170-00010|issn=1539-3704|pmc=1892816|pmid=16418412}}</ref>. The dose of methadone or buprenorphine has implications for the risk of opioid tolerance and increased post-operative pain. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery <ref>{{Cite web|title=UCSF Guideline for the Perioperative Management of Buprenorphine|url=https://www.fresno.ucsf.edu/wp-content/uploads/2021/06/UCSF-Perioperative-Management.pdf|url-status=live}}</ref>. At doses lower than 8 mg/day, buprenorphine can be continued through procedure day and day of discharge. Similarly, it is recommended that patients on methadone continue their home dosing peri-operatively [https://www.uptodate.com/contents/management-of-acute-pain-in-adults-with-opioid-use-disorder?sectionName=PATIENTS%20ON%20METHADONE%20MAINTENANCE%20THERAPY&search=opioid%20use%20disorder&topicRef=108803&anchor=H1466851997&source=see_link#H2641062116].  


Non-opioid agents such as Tylenol and gabapentin. Gabapentin has been shown to promote drug-abstinence in patient on outpatient methadone therapy.<ref>{{Cite journal|last=Compton|first=Peggy|last2=Kehoe|first2=Priscilla|last3=Sinha|first3=Karabi|last4=Torrington|first4=Matt A.|last5=Ling|first5=Walter|date=2010-06-01|title=Gabapentin improves cold-pressor pain responses in methadone-maintained patients|url=https://pubmed.ncbi.nlm.nih.gov/20163921/|journal=Drug and Alcohol Dependence|volume=109|issue=1-3|pages=213–219|doi=10.1016/j.drugalcdep.2010.01.006|issn=1879-0046|pmc=2875370|pmid=20163921}}</ref> A shared neuro-inflammatory and central sensitization process akin to that of neuropathic pain may explain the cross-benefit it has in patients with opioid-induced hyperalgesia.   
Non-opioid agents such as Tylenol and gabapentin/pregabalin. A shared neuro-inflammatory and central sensitization process akin to that of neuropathic pain may explain the cross-benefit of gabapentin in patients with opioid-induced hyperalgesia <ref>{{Cite journal|last=Compton|first=Peggy|last2=Kehoe|first2=Priscilla|last3=Sinha|first3=Karabi|last4=Torrington|first4=Matt A.|last5=Ling|first5=Walter|date=2010-06-01|title=Gabapentin improves cold-pressor pain responses in methadone-maintained patients|url=https://pubmed.ncbi.nlm.nih.gov/20163921/|journal=Drug and Alcohol Dependence|volume=109|issue=1-3|pages=213–219|doi=10.1016/j.drugalcdep.2010.01.006|issn=1879-0046|pmc=2875370|pmid=20163921}}</ref>.   


=== Intraoperative management ===
=== Intraoperative management ===
Regional anesthesia techniques  
Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) are should be strongly considered in a non-opioid driven anesthetic. Ketamine is a useful adjunct due to it's useful effect of increasing opioid sensitivity when run at low dose rates (0.3 mg/kg/hr). Providers should consider Toradol and redosing of Tylenol in longer procedures.


Ketamine is a useful adjunct in
Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression seen older patients, those with OSA, and patients with end-organ failure. 


=== Postoperative management ===
=== Postoperative management ===
Consider post-operative stay in the ICU for pain management and consultation of in-house pain service. Buprenorphine can be safely ordered at patient's reported dosing for post-operative pain management as it is unlikely to cause respiratory depression.
Consider continuing methadone and buprenorphine as part of the post-operative pain management plan. Buprenorphine is unlikely to cause respiratory depression and causes less drug euphoria. Naloxone should not be co-administered due to the risk of causing acute withdrawal.
 
Providers should continue typical regimens for mild-severe pain post-op (oxycodone, fentanyl, hydromorphone), however higher than normal starting doses of opioids may be required. The typical calculation of milligram morphine equivalents (MME) do not give an accurate sense of equivalent dosing.
 
Consider post-operative stay in the ICU for pain management and consultation of in-house pain service.  


== References ==
== References ==
Compton P, Kehoe P, Sinha K, Torrington MA, Ling W. Gabapentin improves cold-pressor pain responses in methadone-maintained patients. Drug Alcohol Depend. 2010 Jun 1;109(1-3):213-9. doi: 10.1016/j.drugalcdep.2010.01.006. Epub 2010 Feb 16. PMID: 20163921; PMCID: PMC2875370.
[[Category:Comorbidities]]
[[Category:Comorbidities]]

Revision as of 17:57, 2 August 2022

Opioid use disorder
Anesthetic relevance

High

Anesthetic management

Use non-opioid pain adjuncts (regional, GABA agonists, NSAIDs) and higher dosing of full mu receptor agonist opioid analgesics (e.g. fentanyl, hydromorphone)

Specialty

Pain

Signs and symptoms

{{{signs_symptoms}}}

Diagnosis

{{{diagnosis}}}

Treatment

{{{treatment}}}

Article quality
Editor rating
In development
User likes
2

This article focuses primarily on management considerations for patients on Suboxone therapy.

Epidemiology

Anesthetic implications

Patient's with opioid use disorder on maintenance therapy with Suboxone (buprenorphine-naloxone) or methadone are at high risk of inadequately controlled pain post-procedure due to low dosing or slow titration.

Pathophysiology

Buprenorphine is a partial mu-opioid receptor agonist and kappa-opioid receptor. It is unique in that its action at the mu-opioid receptor can block binding of other opioids.

Anesthetic management

Preoperative optimization

Patients can continue to receive adequate pain control peri-operatively while continuing on their home opioid agonist therapy[1]. The dose of methadone or buprenorphine has implications for the risk of opioid tolerance and increased post-operative pain. According to UCSF guidelines for perioperative management of buprenorphine, for example, patients on a high dose of buprenorphine (>8 mg/day) should consider gradual dose reduction prior to elective surgery [2]. At doses lower than 8 mg/day, buprenorphine can be continued through procedure day and day of discharge. Similarly, it is recommended that patients on methadone continue their home dosing peri-operatively [1].

Non-opioid agents such as Tylenol and gabapentin/pregabalin. A shared neuro-inflammatory and central sensitization process akin to that of neuropathic pain may explain the cross-benefit of gabapentin in patients with opioid-induced hyperalgesia [3].

Intraoperative management

Regional anesthesia techniques (including continuous epidural and peripheral nerve catheters) are should be strongly considered in a non-opioid driven anesthetic. Ketamine is a useful adjunct due to it's useful effect of increasing opioid sensitivity when run at low dose rates (0.3 mg/kg/hr). Providers should consider Toradol and redosing of Tylenol in longer procedures.

Otherwise, the use of full mu-opioid receptor agonists (fentanyl, hydromorphone) remain important to the management of intraoperative pain. Providers should consider scheduled dosing throughout the procedure balancing the risk of hypotension and respiratory depression seen older patients, those with OSA, and patients with end-organ failure.

Postoperative management

Consider continuing methadone and buprenorphine as part of the post-operative pain management plan. Buprenorphine is unlikely to cause respiratory depression and causes less drug euphoria. Naloxone should not be co-administered due to the risk of causing acute withdrawal.

Providers should continue typical regimens for mild-severe pain post-op (oxycodone, fentanyl, hydromorphone), however higher than normal starting doses of opioids may be required. The typical calculation of milligram morphine equivalents (MME) do not give an accurate sense of equivalent dosing.

Consider post-operative stay in the ICU for pain management and consultation of in-house pain service.

References

  1. Alford, Daniel P.; Compton, Peggy; Samet, Jeffrey H. (2006-01-17). "Acute pain management for patients receiving maintenance methadone or buprenorphine therapy". Annals of Internal Medicine. 144 (2): 127–134. doi:10.7326/0003-4819-144-2-200601170-00010. ISSN 1539-3704. PMC 1892816. PMID 16418412.
  2. "UCSF Guideline for the Perioperative Management of Buprenorphine" (PDF).
  3. Compton, Peggy; Kehoe, Priscilla; Sinha, Karabi; Torrington, Matt A.; Ling, Walter (2010-06-01). "Gabapentin improves cold-pressor pain responses in methadone-maintained patients". Drug and Alcohol Dependence. 109 (1–3): 213–219. doi:10.1016/j.drugalcdep.2010.01.006. ISSN 1879-0046. PMC 2875370. PMID 20163921.