Advertisement

A 35-Year-Old Opioid-Tolerant Patient with Uncontrolled Pain After Surgery

  • Darshan Patel
  • Dalia H. ElmoftyEmail author
Chapter
  • 48 Downloads

Abstract

In 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) advocated for pain to be the “fifth vital sign” and, ever since, the use of opioids for pain management has increased exponentially each year (Gulur, et al., Pain Physician. 17:E503–7, 2014). Mistakenly, opioids are thought of as the first line of treatment for pain. The United States appears to be the main consumer of opioids accounting for 56% of morphine and 81% of oxycodone usage globally (International Narcotics Control Board. Narcotic drugs technical reports. Estimated world requirements for 2011. https://www.incb.org. Accessed 24 May 2018). There is growing evidence that opioids may have a negative impact on pain, especially postoperative pain. Studies show that chronic opioid exposure can lead to opioid tolerance or opioid-induced hyperalgesia (OIH)—two distinct phenomena that are directly related to opioid therapy and are often difficult to control. Clinical differentiation between these two phenomena can be challenging. Anesthetic technique can influence the development of opioid tolerance and OIH. A multimodal approach is recommended and includes preemptive analgesia, intraoperative infusion therapy, consideration of regional techniques, and maximizing the use of non-opioid medications.

Keywords

Postsurgical pain Opioids-induced tolerance Opioids-induced hyperalgesia Multimodal analgesia Regional analgesia Infusion therapy 

References

  1. 1.
    Gulur P, Williams L, Chaudhary S, Koury K, Jaff M. Opioid tolerance—a predictor of increased length of stay and higher readmission rates. Pain Physician. 2014;17(4):E503–7.PubMedGoogle Scholar
  2. 2.
    International Narcotics Control Board. Narcotic drugs technical reports. Estimated world requirements for 2011. https://www.incb.org. Accessed 24 May 2018.
  3. 3.
    Food and Drug Administration. Extended-release (ER) and long-acting (LA) opioid analgesics risk evaluation and mitigation strategy (REMS). FDA REMS modification. 2015;10.Google Scholar
  4. 4.
    Hadi I, Morley-Forster PK, Dain S, Horrill K, Moulin DE. Brief review: perioperative management of the patient with chronic non-cancer pain. Can J Anesth. 2006;53(12):1190–9.CrossRefGoogle Scholar
  5. 5.
    Lewis NL, Williams JE. Acute pain management in patients receiving opioids for chronic and cancer pain. Continuing Education in Anaesthesia, Critical Care & Pain. 2005;5(4):127–9.CrossRefGoogle Scholar
  6. 6.
    Mahathanaruk M, Hitt J, de LeonCasasola OA. Perioperative management of the opioid tolerant patient for orthopedic surgery. Anesthesiol Clin. 2014;32(4):923–32.CrossRefGoogle Scholar
  7. 7.
    Hayhurst CJ, Durieux ME. Differential opioid tolerance and opioid-induced hyperalgesia: a clinical reality. Anesthesiology. 2016;124(2):483–8.CrossRefGoogle Scholar
  8. 8.
    Tumber PS. Optimizing perioperative analgesia for the complex pain patient: medical and interventional strategies. Canadian J Anesth. 2014;61(2):131–40.CrossRefGoogle Scholar
  9. 9.
    Janssen KJ, Kalkman CJ, Grobbee DE, Bonsel GJ, Moons KG, Vergouwe Y. The risk of severe postoperative pain: modification and validation of a clinical prediction rule. Anesth Analg. 2008;107(4):1330–9.CrossRefGoogle Scholar
  10. 10.
    Melnyk M, Casey RG, Black P, Koupparis AJ. Enhanced recovery after surgery (ERAS) protocols: time to change practice? Can Urol Assoc J. 2011;5:342.CrossRefGoogle Scholar
  11. 11.
    Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292–8.CrossRefGoogle Scholar
  12. 12.
    Manfredi PL, Houde RW. Prescribing methadone, a unique analgesic. J Support Oncol. 2003;1(3):216.PubMedGoogle Scholar
  13. 13.
    Toombs JD, Kral LA. Methadone treatment for pain states. Am Fam Physician. 2005;71(7):1353–8.PubMedGoogle Scholar
  14. 14.
    Lee M, Silverman S, Hansen H, Vikram P. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011;14:145–61.PubMedGoogle Scholar
  15. 15.
  16. 16.
    Tröster A, Sittl R, Singler B, Schmelz M, Schüttler J, Koppert W. Modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by parecoxib in humans. Anesthesiology. 2006;105(5):1016–23.CrossRefGoogle Scholar
  17. 17.
    Koppert W, Sittl R, Scheuber K, Alsheimer M, Schmelz M, Schüttler J. Differential modulation of remifentanil-induced analgesia and postinfusion hyperalgesia by S-ketamine and clonidine in humans. Anesthesiology. 2003;99(1):152–9.CrossRefGoogle Scholar
  18. 18.
    De Oliveira GS, Castro-Alves LJ, Khan JH, McCarthy RJ. Perioperative systemic magnesium to minimize postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology. 2013;119(1):178–90.CrossRefGoogle Scholar
  19. 19.
  20. 20.
    Lin TF, Yeh YC, Lin FS, Wang YP, Lin CJ, Sun WZ, Fan SZ. Effect of combining dexmedetomidine and morphine for intravenous patient-controlled analgesia. Br J Anaesth. 2008;102(1):117–22.CrossRefGoogle Scholar
  21. 21.
    Elmofty D. Opioid-induced hyperalgesia, tolerance and chronic postsurgical pain; a dilemma complicating postoperative pain management. In: Anitescu A, editor. Pain management review: a problem-based learning approach. New York, NY, USA: Oxford University Press. p. 303–9.Google Scholar
  22. 22.
    Freise H, Van Aken HK. Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth. 2011;107(6):859–68.CrossRefGoogle Scholar
  23. 23.
    Siddiqui MR, Sajid MS, Uncles DR, Cheek L, Baig MK. A meta-analysis on the clinical effectiveness of transversus abdominis plane block. J Clin Anesth. 2011;23(1):7–14.CrossRefGoogle Scholar
  24. 24.
    Finnerty O, Carney J, McDonnell JG. Trunk blocks for abdominal surgery. Anaesthesia. 2010;65(s1):76–83.CrossRefGoogle Scholar
  25. 25.
    Dunn LK, Durieux ME. Perioperative use of intravenous lidocaine. Anesthesiology. 2017;126(4):729–37.CrossRefGoogle Scholar
  26. 26.
    Shah S, Kapoor S, Durkin B. Analgesic management of acute pain in the opioid-tolerant patient. Curr Opin Anesthesiol. 2015;28(4):398–402.CrossRefGoogle Scholar
  27. 27.
    Silverman SM. Opioid induced hyperalgesia: clinical implications for the pain practitioner. Pain Physician. 2009;12(3):679–84.PubMedGoogle Scholar
  28. 28.
    Juni A, Cai M, Stankova M, Waxman AR, Arout C, Klein G, Dahan A, Hruby VJ, Mogil JS, Kest B. Sex-specific mediation of opioid-induced hyperalgesia by the melanocortin-1 receptor. Anesthesiology. 2010;112(1):181–8.CrossRefGoogle Scholar
  29. 29.
    Jensen KB, Lonsdorf TB, Schalling M, Kosek E, Ingvar M. Increased sensitivity to thermal pain following a single opiate dose is influenced by the COMT val158met polymorphism. PLoS One. 2009;4(6):e6016.CrossRefGoogle Scholar
  30. 30.
    Edwards R, Wasan A, Jamison R. Hyperalgesia in pain patients at elevated risk for opioid misuse. J Pain. 2010;11(4):S45.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of AnesthesiologySt. Francis Medical CenterEvanstonUSA
  2. 2.Department of AnesthesiaUniversity of ChicagoChicagoUSA

Personalised recommendations