The challenge of perioperative pain management in opioid-tolerant patients

Figures & data

Table 1 Clinical differentiation between opioid users for chronic pain and opioid abusers

	Opioid users for chronic pain	Opioid abusers
Use of opioids	Appropriate Declared	Out of control Often deliberately omitted
Quality of life	Improved by opioids	Impaired by opioids
Awareness of opioid-related side effects	Complete	Unconcerned
Diagnosis	Available	Unavailable
Treatment plan and medical prescription	Followed	Unavailable
Opioid medication	Available	Hidden, illicit

Table 2 Signs and symptoms of opioid abuse and opioid withdrawal

Opioid abuse	Opioid withdrawal
Vomiting	Dysphoric mood
Pruritus	Nausea or vomiting
Sweating	Lacrimation
Twitching	Rhinorrhea
Miosis (contracted pupils)	Muscle aches
Loss of appetite	Pupillary dilation
Drowsiness	Piloerection
Respiratory depression	Sweating
Coma	Diarrhea
Needle marks	Yawning
	Fever
	Insomnia

Table 3 Perioperative treatment plan for opioid-tolerant patients

I	Identify the problem and specific risk factors
D	Define a plan of perioperative pain management, involving anesthesiologists, surgeons, nurses, and family members
E	Explore possible strategies: use multimodal analgesia and regional techniques, when applicable
A	Act on the strategies: aggressively treat pain and prevent withdrawal
L	Look back: evaluate the analgesic effect, functional status, and adverse events

Table 4 Equianalgesic doses of opioids

Opioid	Approximate oral equianalgesic dose	Onset	Duration	Half-life
Morphine (reference drug)*	30 mg	2–3 h	8–12 h	2–4 h
Tramadol*	150 mg	1–2 h	8–12 h	2–4 h
Codeine (with APAP)	200 mg	30–60 min	4–8 h	3–4 h
Oxycodone*	20 mg	1–2 h	6–10 h	3–4 h
Tapentadol*	100 mg	1–2 h	8–12 h	2–4 h
Hydromorphone#	7.5 mg	12–14 h	20–24 h	8–16 h
Oxymorphone	10 mg	30–45 min	4–6 h	2–3 h
Hydrocodone (with APAP, ASA, or ibuprofen)	30 mg	15–30 min	4–8 h	2–3 h

Notes:

* PKs (pharmacokinetics) refer to slow release twice daily (BID) formulations.

# PKs refer to once daily hydromorphone formulation.

Abbreviations: APAP, acetaminophen; ASA, acetylsalicylic acid.