Management Of Acute Perioperative Pain Research Articles

NCPD Tests: Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence into Practice.

NCPD Tests: Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence into Practice.

Acute Perioperative Pain Management of the Orthopaedic Patient: Guidance for Operationalizing Evidence Into Practice.

Orthopaedic surgery often results in pain, with less than half of patients reporting adequate relief. Unrelieved acute pain occurring after surgery increases the risk of negative sequelae, including delayed healing, increased morbidity, pulmonary complications, limited rehabilitation participation, anxiety, depression, increased length of stay, prolonged duration of opioid use, and the development of chronic pain. Interventions that are individualized, evidence-informed, and applied within an ethical framework improve healthcare delivery for patients, clinicians, and healthcare organizations. Recommendations for using the principles of effective pain management from preoperative assessment through discharge are detailed, including recommendations for addressing barriers and challenges in applying these principles into clinical practice.

An Appraisal of Using Opioids in Patients with Opioid Use Disorder.

Podiatric physicians have come to realize that opioid use disorder (OUD) is a public health crisis causing morbidity, mortality, lost productivity, and legal cost in the United States. Opioid analgesics are efficient first-line pain relievers for acute and chronic lower-extremity pain syndrome. Perioperative pain management strategies have been proposed using opioid stewardship, but there are few standardized protocols to guide podiatric medical providers treating patients with OUD. First, we describe the pharmacology of therapeutic agents used as medications for addiction treatment for OUD and substance use disorder (SUD). Second, we offer criteria for selecting acute pain and perioperative management in patients with OUD and SUD per current medical literature. Finally, we review the literature applying opioid stewardship in the context of prescribing opioid analgesics in the presence of OUD and SUD. Three hypothetical clinical scenarios grounded in clinical-based literature are described with congruent data and founded guidelines. The first and second scenarios describe acute pain and perioperative management in patients with OUD receiving methadone and buprenorphine-naloxone, respectively. The third scenario describes acute pain and perioperative management in a patient with SUD receiving intravenous naltrexone. We hope that the lower-extremity specialist will appreciate that thoughtful management of acute perioperative pain among patients who receive medications for addiction treatment for OUD is critically important given the risks of destabilization during the perioperative period. The literature reveals the lack of rigorous evidence on acute pain management in patients who receive medication for OUD; however, some clinical evidence supports the practice of continuing methadone or buprenorphine for most patients during acute pain episodes.

Non-pharmacological Options in Postoperative Hospital-Based and Rehabilitation Pain Management (NOHARM): Protocol for a Stepped-Wedge Cluster-Randomized Pragmatic Clinical Trial.

IntroductionOpioids may be necessary for guideline-concordant acute perioperative pain management, but their use carries risks for unintended prolonged use and addiction. Guidelines recommend use of validated non-pharmacological pain care (NPPC) approaches in conjunction with prescribed opioids and other analgesics. Our protocol outlines a population-level, pragmatic trial that will test a bundled intervention comprised of an electronic health record (EHR) portal-based conversation guide, EHR clinical decision support (CDS), and a suite of self-management educational and support materials to encourage and advance NPPC use.MethodsWe are conducting a stepped-wedge, cluster-randomized pragmatic trial spanning seven surgical specialties across six geographically diverse locations within the Mayo Clinic Enterprise. Thirty two surgical practices across six locations (Rochester, Minnesota; Mankato, Minnesota; La Crosse, Wisconsin; Eau Claire, Wisconsin; Phoenix, Arizona; Jacksonville, Florida) comprise 22 distinct practice clusters that are randomly assigned to one of five steps using constrained randomization. Steps “go live” by initiating the intervention at 7-month intervals between March 2021 and July 2023. Patients over 18 years of age who are scheduled for qualifying procedures within “live” consenting practices are sent a Healing After Surgery guide via their patient portals pre-operatively, directing them to identify their preferred NPPC modalities among 13 approaches. These selections create CDS options for care teams to support patients with self-management materials that reinforce safe NPPC use.Planned OutcomesPatients’ clinical, demographic, and outcome data will be abstracted from the Epic EHR. Primary outcomes will be the Patient Reported Outcomes Measurement Information System (PROMIS) pain interference and physical functioning computer adaptive tests (CAT) collected at 1, 2, and 3 months postoperatively via the patient portal. We will mail printed versions of the 6-item PROMIS short forms to portal non-responders to minimize bias. Secondary outcomes will include the PROMIS anxiety CAT, opioid consumption, and self-reported NPPC use.Trial RegistrationClinicalTrials.gov identifier, NCT04570371.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40122-022-00393-x.

Regional anesthesia and acute perioperative pain management in thoracic surgery: a narrative review.

Background and ObjectiveThoracic surgery causes significant pain which can negatively affect pulmonary function and increase risk of postoperative complications. Effective analgesia is important to reduce splinting and atelectasis. Systemic opioids and thoracic epidural analgesia (TEA) have been used for decades and are effective at treating acute post-thoracotomy pain, although both have risks and adverse effects. The advancement of thoracoscopic surgery, a focus on multimodal and opioid-sparing analgesics, and the development of ultrasound-guided regional anesthesia techniques have greatly expanded the options for acute pain management after thoracic surgery. Despite the expansion of surgical techniques and analgesic approaches, there is no clear optimal approach to pain management. This review aims to summarize the body of literature regarding systemic and regional anesthetic techniques for thoracic surgery in both thoracotomy and minimally invasive approaches, with a goal of providing a foundation for providers to make individualized decisions for patients depending on surgical approach and patient factors, and to discuss avenues for future research.MethodsWe searched PubMed and Google Scholar databases from inception to May 2021 using the terms “thoracic surgery”, “thoracic surgery AND pain management”, “thoracic surgery AND analgesia”, “thoracic surgery AND regional anesthesia”, “thoracic surgery AND epidural”. We considered articles written in English and available to the reader.Key Content and FindingsThere is a wide variety of strategies for treating acute pain after thoracic surgery, including multimodal opioid and non-opioid systemic analgesics, regional anesthesia including TEA and paravertebral blocks (PVB), and a recent expansion in the use of novel fascial plane blocks especially for thoracoscopy. The body of literature on the effectiveness of different approaches for thoracotomy and thoracoscopy is a rapidly expanding field and area of active debate.ConclusionsThe optimal analgesic approach for thoracic surgery may depend on patient factors, surgical factors, and institutional factors. Although TEA may provide optimal analgesia after thoracotomy, PVB and emerging fascial plane blocks may offer effective alternatives. A tailored approach using multimodal systemic therapies and regional anesthesia is important, and future studies comparing techniques are necessary to further investigate the optimal approach to improve patient outcomes.

Acute Perioperative Pain Management Among Adult Patients Undergoing Orthopaedic Surgery.

Arkin, Laura C.; Lyons, Mary T.; A. McNaughton, Molly; Quinlan-Colwell, Ann Author Information

Position Statement: Acute Perioperative Pain Management Among Patients Undergoing Orthopedic Surgery by the American Society for Pain Management Nursing and The National Association of Orthopaedic Nurses

Patients undergoing elective orthopaedic surgery may experience pain that is acute, chronic or a combination of the two, with less than half of all surgical patients reporting adequate pain relief. The National Association of Orthopaedic Nurses (NAON) and the American Society for Pain Management Nursing (ASPMN) have partnered to provide evidence-informed guidance to empower nurses to employ effective pain management. Understanding and applying ethical, evidence-informed, patient-focused, interprofessional interventions will improve outcomes for patients, clinicians, and healthcare organizations. Together, we encourage nurses to embrace the guiding principles presented in this Position Statement to provide optimal pain management for the orthopaedic patient.

Nonopioid Analgesics for the Perioperative Geriatric Patient: A Narrative Review.

Management of acute perioperative pain in the geriatric patient can be challenging as the physiologic and pharmacokinetic changes associated with aging may predispose older patients to opioid-related side effects. Furthermore, elderly adults are more susceptible to postoperative delirium and postoperative cognitive dysfunction, which may be exacerbated by both poorly controlled postoperative pain and commonly used pain medications. This narrative review summarizes the literature published in the past 10 years for several nonopioid analgesics commonly prescribed to the geriatric patient in the perioperative period. Nonopioid analgesics are broken down as follows: medications prescribed throughout the perioperative period (acetaminophen and nonsteroidal anti-inflammatory drugs), medications limited to the acute perioperative setting ( N -methyl-D-aspartate receptor antagonists, dexmedetomidine, dexamethasone, and local anesthetics), and medications to be used with caution in the geriatric patient population (gabapentinoids and muscle relaxants). Our search identified 1757 citations, but only 33 specifically focused on geriatric analgesia. Of these, only 21 were randomized clinical trials' and 1 was a systematic review. While guidance in tailoring pain regimens that focus on the use of nonopioid medications in the geriatric patient is lacking, we summarize the current literature and highlight that some nonopioid medications may extend benefits to the geriatric patient beyond analgesia.

Opioid use disorder in anaesthesia and intensive care: Prevention, diagnosis and management.

Opioid misuse is common, as is opioid agonist treatment of opioid dependence. Almost 3% of Australians and over 3.5% of those living in New Zealand report misuse of analgesics. Over 50,000 Australians receive opioid agonist treatment with methadone or buprenorphine for management of severe opioid use disorder.The perioperative period is an opportunity to identify pre-existing opioid misuse, and to introduce interventions to reduce the risk of development of opioid use disorder. Challenges of acute perioperative pain management or intensive care management of patients receiving opioid agonist treatment include opioid tolerance and ongoing prescribing of methadone or buprenorphine. There has been some ambiguity about the optimal perioperative management of buprenorphine, a partial agonist at the mu receptor.In this article, a framework to identify emerging opioid misuse problems, identify risk of overdose and to manage the opioid-dependent patient on opioid agonist treatment perioperatively or in the intensive care unit is provided. Diagnostic criteria and risk stratification criteria are presented. Management strategies include trauma-informed care, care planning and care coordination with community practitioners and opioid agonist treatment providers. Continuing methadone or buprenorphine perioperatively with additional opioid and non-opioid analgesia is generally recommended. Increased opioid agonist treatment doses may be required on discharge. An algorithm for decisions about opioid agonist treatment management in the intensive care unit based on the risks of opioid withdrawal and toxicity is considered. Strategies for managing the opioid-dependent patient who is not in treatment are also discussed.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public–private partnership which led to the publication of its report in 2019. The report emphasized...

Concordance between the loss of resistance technique and ultrasound in measuring the distance from the skin to the epidural space in pediatric patients: Observational study

Introduction: The use of ultrasound in regional anesthesia has become a standard technique to improve nerve block accuracy and reduce associated complications. The literature reports a good correlation between the distance from the skin to the dura mater or the ligamentum flavum measured on ultrasound and the conventional technique of “loss of resistance”. Latin American populations have not been included in the studies conducted so far but, because of differences in physical build, it is important to determine whether this correlation is maintained in the various populations. This paper offers new information about the role of ultrasound in determining the distance to the ligamentum flavum and recognizing the proximity of the dura mater to avoid accidental puncture of this structure in Latin American populations.
 Objective: To determine correlation and concordance in estimating the distance from the skin to the epidural space between the loss of resistance technique and ultrasound measurement.
 Methodology: Observational study conducted in 52 pediatric patients who received general anesthesia plus peridural analgesia for acute perioperative pain management between July 2014 and November 2015 to assess correlation and concordance between loss of resistance and ultrasound measurement of distance to the epidural space.
 Results: There is a correlation between distances measured using the two techniques, which appears to be higher as patient age increases. As for concordance, the study found that 0.43 cm should be added to the ultrasound measurement to achieve agreement with the distance obtained using the loss of resistance technique; however, the interval between the two measurements is 1.15 cm.
 Conclusions: A correlation was found between the measurement taken from the skin to the peridural space using ultrasound and the measurement obtained with the traditional needle puncture and loss of resistance technique. Although concordance was not as expected and the distance measured with ultrasound may be smaller than the real measurement with the needle, ultrasound offers good guidance regarding proximity to the peridural space.

A Practical Approach to Acute Postoperative Pain Management in Chronic Pain Patients

In the United States, more than 100 million people suffer from chronic pain. Among patients presenting for surgery, about one in four have chronic pain. Acute perioperative pain management in this population is challenging because many patients with chronic pain require long-term opioids for the management of this pain, which may result in tolerance, physical dependence, addiction, and opioid-induced hyperalgesia. These challenges are compounded by the ongoing opioid epidemic that has resulted in calls for a reduction in opioid use, with a concurrent increase in the number of patients with chronic opioid exposure presenting for surgery. This article aims to summarize practical considerations for acute postoperative pain management in patients with chronic pain conditions. A patient-centered acute pain management plan, including nonopioid analgesics, regional anesthesia, and careful selection of opioid medications, can lead to adequate analgesia and satisfaction with care. Also, a meticulous rotation from one opioid to another may decrease opioid requirement, increase analgesic effectiveness, and improve satisfaction with care.

Anesthesia and perioperative pain management during cardiac electronic device implantation.

BackgroundThe degree of pain caused by the implantation of cardiac electronic devices (CEDs) and the type of anesthesia or perioperative pain management used with the procedure have been insufficiently studied. The aim of this study was to analyze perioperative pain management, as well as intensity and location of pain among patients undergoing implantation of CED, and to compare the practice with published guidelines.Patients and methodsThis was a combined retrospective and prospective study conducted at the tertiary hospital, University Hospital Split, Croatia. The sample included 372 patients who underwent CED implantation. Perioperative pain management was analyzed retrospectively in 321 patients who underwent CED implantation during 2014. In a prospective study, intensity and location of pain before, during, and after the procedure were measured by using a numerical rating scale (NRS) ranging from 0 to 10 in 51 patients at the same institution from November 2014 to August 2015.ResultsA quarter of patients received analgesia or sedation before surgery. All the patients received local lidocaine anesthesia. After surgery, 31% of patients received pain medication or sedation. The highest pain intensity was observed during CED implantation with the highest NRS pain score being 8. Some patients reported severe pain (NRS >5) also at 1, 3, 6, 8, and 24 hours after surgery. The most common pain locations were surgical site, shoulder, and chest. Adherence to guidelines for acute perioperative pain management was insufficient.ConclusionPatients may experience severe pain during and after CED implantation. Perioperative pain management was suboptimal, and higher doses of sedation and intensive analgesia are required. Guidelines for acute perioperative pain management and anesthesia during CED implantation should be developed.

Acute Perioperative Pain Management in Total Joint Arthroplasty: Summary of Available Agents

Dr. Misra is Assistant Professor, Department of Anesthesiology, Mayo Clinic, 5777 East Mayo Blvd, Phoenix, AZ 85253; E-mail: [email protected] The author and all staff in a position to control the content of this CME activity have disclosed that they and their spouses/life partners (if any) have no financial relationships with, or financial interests in, any commercial organizations pertaining to this educational activity.CME AccreditationLippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. To earn CME credit, you must read the CME article and complete the quiz and evaluation assessment survey on the enclosed form, answering at least 70% of the quiz questions correctly. This CME activity expires on January 31, 2018.CNE AccreditationLippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. LWW, publisher of Topics in Pain Management, will award 1.0 contact hours for this continuing nursing education activity. This activity has been assigned 1.0 pharmacology credits. Instructions for earning ANCC contact hours are included on page 11 of the newsletter. This CNE activity expires on February 28, 2019.

Analysis of perioperative pain management in vascular surgery indicates that practice does not adhere with guidelines: a retrospective cross-sectional study.

BackgroundInadequate treatment of pain related to surgery may be associated with complications and prolonged recovery time and increased morbidity and mortality rates. We investigated perioperative pain management in vascular surgery and compared it with the relevant guidelines for the treatment of perioperative pain.MethodsWe conducted a retrospective study on 501 patients who underwent vascular surgery at the University Hospital Split, Croatia. We collected the following data from patients’ charts: age, gender, premedication, preoperative patient’s physical status, type of surgery, duration of surgery and anesthesia, type of anesthesia, postoperative analgesia, and need for intensive care. We examined departmental procedures to assess adherence to guidelines for perioperative pain management.ResultsNone of the 501 patients’ charts recorded information about perioperative pain intensity, 28% of patients did not receive any medication the night before their elective surgical procedures, and 17% of patients did not receive premedication immediately before the procedure. Most patients (66%) did not receive any pain medication in the operating room after surgery. Following surgery, 36% of patients were monitored in the intensive care units, while the rest were released to the ward. Some patients (17%) did not receive any analgesia after surgery. Procedures at the department did not adhere to the current recommendations for perioperative pain management.ConclusionThe study indicates that management of surgery-related pain in complex vascular procedures at this hospital did not follow guidelines for the management of acute perioperative pain. Our finding that most patients did not receive appropriate analgesia after vascular surgery leads to the conclusion that the institution would benefit from developing guidelines for the management of acute perioperative pain, which should be applied in all cases.

Iontophoretic transdermal fentanyl for the management of acute perioperative pain in hospitalized patients

ABSTRACTIntroduction: Intravenous (I.V.) morphine administered through a patient-controlled system currently represents the gold standard treatment for moderate to severe acute postoperative pain. To fix the limitations showed by the available I.V. patient-controlled analgesia (PCA) systems that may restrict its use in the clinical practice a needle-free, iontophoretic, fentanyl patient-controlled transdermal system has been developed and recently approved by the United States Food and Drug Administration (FDA) and by the European Medicines Agency (EMA).Areas covered: This review aims at describing the technology, pharmacology and clinical efficacy of fentanyl iontophoretic transdermal system (ITS) in the treatment of acute pain. A literature search was conducted in the PUBMED database using the term ‘fentanyl iontophoretic transdermal system’ through September 2015 and results from the main clinical trials are discussed.Expert opinion: In 2015, the appropriate treatment of acute pain after surgery is still a challenge and it represents a primary goal in the care of the surgical patient. When regional analgesia techniques are not applicable and systemic analgesia is required, patient controlled systems represent the standard of care for opioid administration. The fentanyl ITS presents several potential advantages compared to the currently used PCA devices. In particular, it does not require intravenous lines and eliminates the potential for drug administration errors, observed with manually programmed standard PCA devices. Nevertheless, further studies are needed to address eventual inter-individual variability especially for opioid tolerant patients.

The use of intravenous infusion or single dose of low-dose ketamine for postoperative analgesia: a review of the current literature.

As an analgesic and N-methyl-D-aspartate receptor antagonist, ketamine has been increasingly used as an adjunct in the management of acute perioperative pain. Although several meta-analyses have examined low-dose intravenous (i.v.) ketamine, they do not distinguish between different types of infusions. Additionally, the many clinical trials published on ketamine vary by regimen of administration and surgical site. This review seeks to exclusively examine the evidence supporting the use of low-dose i.v. infusion of ketamine for the management of perioperative pain. We searched Medline for any clinical trials or meta-analyses that were conducted on low-dose i.v. infusion of ketamine between 1966 and November 2013. Using six equations, we were left with 695 references. Of those, five meta-analyses and 39 clinical trials met the criteria to be included our review. These clinical trials represent 2,482 patients, 1,403 of whom received ketamine. We then examined the efficacy of low-dose i.v. ketamine by regimen and site of surgery using pain scores and opioid consumption as endpoints. Finally, we assessed the safety and long-term impact of low-dose ketamine. Low-dose i.v. ketamine reduces opioid consumption by 40%. It also lowers pain scores, but these findings are less clear. No major complications have been reported with low-dose i.v. infusion of ketamine when given up to 48 hours after surgery. While our review lends support to using low-dose i.v. infusion of ketamine in the management of perioperative pain, its optimal dose and regimen remain to be determined. Thirty-nine clinical trials assessed a continuous infusion or a bolus of low-dose ketamine for postoperative analgesia using reduction of pain scores or reduction of the opioid consumption as the primary endpoint. The mean reduction of opioid consumption when using low-dose i.v. infusion ketamine (infusion rate less than 1.2 mg/kg/h) is 40%. Ketamine also reduces pain scores, but the amplitude of the effect is less clear. No major complications have been reported with low-dose i.v. infusion of ketamine up to 48 hours following surgery.

Clonidine for management of chronic pain: A brief review of the current evidences

Clonidine, an alpha-2 adrenergic receptor agonist, has well-established role in acute perioperative pain management. However, recently it has found increasing use in chronic pain conditions as well. In this review, we systematically searched and analyzed the clinical studies from “PubMed,” “PubMed central” and “Scopus” database for use of clonidine in the chronic pain. Quantitative meta-analysis was not possible as clonidine has been used in various patient populations through different routes. However, qualitative analysis of nearly thirty clinical studies provides some evidence that clonidine administered through epidural, intrathecal and local/topical route may be effective in chronic pain conditions where neuropathy is a predominant component. It may also be effective where opioids are of limited use due to inadequate pain relief or adverse effects.

An alternative way of managing acute pain in patients who are in buprenorphine opioid substitution therapy programs

Editor, We read with great interest the review article by Stromer et al.1 on the perioperative management of pain in patients who abuse opioids. It adds much to the knowledge base on which we rely to manage such a complex patient group. However, in our experience, there is an alternative and perhaps simpler and more effective way of managing patients who are in buprenorphine opioid substitution therapy (BOST) programs. This is of growing relevance as in many countries the number of such patients is increasing due to the perceived greater safety profile of buprenorphine compared with methadone. We acknowledge that the management of acute perioperative pain in a patient prescribed BOST is controversial.2 We agree that concerns about buprenorphine's long half-life, partial μ-agonist and κ-antagonist effects,1 in addition to its high opioid receptor affinity and slow dissociation from the μ-opioid receptor,3 have led many experts to recommend that it be ceased preoperatively and replaced with methadone or a pure μ-opioid agonist to ensure adequate intraoperative and postoperative pain relief.1,4,5 However, we believe that such concerns are unfounded. Contrary to the management plan suggested by Stromer et al., some authors have recommended that the buprenorphine, even in the high doses of 4 to 32 mg often used in BOST, be continued throughout the perioperative period.2 We, therefore, recently undertook a retrospective cohort study comparing pain relief and patient-controlled analgesia (PCA) opioid requirements in the first 24 h after surgery in 51 patients in methadone opioid substitution therapy (MOST; 29 patients) and BOST (22 patients) programs.3 The patients were further subgrouped into those whose methadone or buprenorphine was given or withheld on the first postoperative day. We found no statistically significant differences in the pain scores (rest and movement) or PCA morphine equivalents used between the MOST and BOST patients, suggesting that even for planned major surgery, adequate intraoperative and postoperative analgesia can be equally achieved for patients taking methadone and buprenorphine. Thus, changing preoperatively from buprenorphine to methadone seems to offer no advantage. Of special interest was that BOST patients who were not given their buprenorphine the day after surgery had statistically significantly higher PCA morphine equivalent requirements in the first 24 h after surgery (though similar pain scores) compared with those who were given their usual dose. As a result, concerns about the ability of high doses of buprenorphine to limit the access of full μ-opioid agonists to opioid receptors and reduce their analgesic efficacy would seem to be unwarranted.3 We also found that the BOST and MOST patients had a higher incidence of increased sedation (a better clinical indicator of early respiratory depression than a decrease in respiratory rate)6 than our opioid-naive patients. Although the reason for this is unclear, it is a finding also noted by Rapp et al.7 in opioid-tolerant patients in general. Thus, when opioid doses are rapidly and significantly escalated to deal with new acute pain in the opioid-tolerant patient2 as recommended by Stromer et al.,1 monitoring for respiratory depression, including using sedation scores, must still be mandated, as these patients may, perhaps counterintuitively, be at greater risk of respiratory depression than the opioid-naive patient. We routinely continue buprenorphine (or any other opioid the patient may be taking in the long-term) throughout the perioperative period, irrespective of its dose or the perceived size of the surgical insult. We manage additional acute pain with a full-agonist PCA opioid in higher-than-usual doses, adjuvant nonopioid analgesic agents including ketamine, and regional analgesia, whenever possible. Acknowledgements relating to this article Assistance with the letter: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.

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Editor, We appreciate Dr Huxtable's and Dr Macintyre's interest1 in our review article about the perioperative management of pain in patients who abuse opioids.2 We have attentively read the letter to the editor by Huxtable et al.3 describing an extremely interesting alternative way of managing acute pain in patients who are in buprenorphine opioid substitution therapy (BOST) programmes.4 Currently, about 15 000 Austrian addicts are in a substitution treatment. Methadone is used in about 20 to 25% of them and buprenorphine in about 10 to 21%. Other substances, such as codeine, are used by only about 1% of these patients.5 The result of the described retrospective cohort study is undoubtedly interesting4 and seems to be a comfortable alternative in the management of acute pain in patients who are in BOST programmes to achieve adequate perioperative analgesia. However, the management of acute perioperative pain in a patient, as reported in the BOST article, depends mainly on local medical treatment regimens. In Austria, buprenorphine is replaced with methadone or a pure μ-opioid agonist throughout the perioperative period for elective major surgery to ensure adequate intraoperative and postoperative pain relief,2,6,7 because of buprenorphine′s well known pharmacological, especially potential μ-antagonistic, characteristics. We remain of the view that addicted patients have to be recognised as a high-risk group in the perioperative period, especially in major surgery, because of their higher perioperative risk for organic and psychological complications. These patients have to be monitored carefully to avoid adverse effects. Therefore, we highly recommend a continuous and careful opioid dose titration to avoid unnecessary complications.2 Acknowledgements relating to this article Assistance with the study: none. Financial support and sponsorship: none. Conflicts of interest: none. Presentation: none.