Perioperative pain management in opioid tolerant and opioid use disorder patients: Considerations for the foot and ankle surgeon

Abstract

Perioperative management of patients with long term use of opioids has become an increasing challenge. Complicating the care of these patients are the misconceptions regarding opioid prescribing in the opioid-tolerant community and those on maintenance therapy. Healthcare providers receive limited education on pain management including multimodal pain control. Perioperative considerations should be examined. Prescribers are encouraged to consider utilizing a multi-modal regimen in this population. This review aims to better educate the foot and ankle surgeon with up-to-date knowledge in working with the opioid-tolerant patient population. A comprehensive literature review was performed, focusing on perioperative pain management in opioid tolerant patients. Expert opinions and material in this review is provided by a board-certified Addiction Medicine Specialist and board-certified Foot and Ankle Surgeon at a level one trauma center. Pain control in the opioid-tolerant patient population can be challenging for the Foot and Ankle surgeon. Pre-operatively, patients' risk factors for chronic opioid use should be assessed through screening tools. Intra-operatively, sound dialogue between the surgeon and anesthesiologist is imperative with new and emerging techniques. Postoperatively opioid-tolerant patients should resume preoperative dosing of opioids at a minimum. A multimodal pain regimen is associated with superior pain relief and decreased opioid consumption. Patients on maintenance therapy including Methadone, and Buprenorphine should continue these medications during the perioperative period. These patients may benefit from an addiction medicine consultation for more comprehensive care.