Acute pain management for opioid dependent patients

Boyle Department of Anaesthesia, St Bartholomew's Hospital, West Smithfied, London EC1A 7BE, UK.
Anaesthesia (Impact Factor: 3.38). 04/2006; 61(3):269-76. DOI: 10.1111/j.1365-2044.2005.04503.x
Source: PubMed


Patients requiring acute pain management may be opioid dependent as a result of either recreational or therapeutic opioid use, including those in opioid addiction programmes. Pain in these patients is often under-estimated and under-treated. In addiction, drug-seeking behaviour differentiates it from simple dependence. With few randomised controlled trials, current evidence predominantly consists of guidelines based on case reports, retrospective studies and expert opinion. Consensus recommendations include maintaining regular provision of the patient's pre-existing opioid requirement, with additional analgesia, ideally multimodal, in appropriate combinations of short-acting opioid (as required), local anaesthesia, and adjuvant anti-inflammatory analgesics and paracetamol. Patient controlled analgesia with higher bolus doses and shorter lock-out intervals is a recommended strategy. Transdermal opioid patches and implantable pumps will continue to deliver opioid, to which non-opioid and short-acting opioids may be added. Re-exposure to opioid is ideally avoided in previously addicted patients, but if not feasible, opioid therapy should be prescribed.

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    • "Treating methadone-maintained patients for acute pain with opioid analgesics has not been found to lead to relapse or higher methadone doses post-treatment.89 The regular, daily methadone dose should be continued, and analgesic medications including nonopioid analgesics or short-acting opioids added as clinically indicated.90,91 Since methadone occupies less than one third of the µ opioid receptors, unoccupied receptors are available for analgesic response.92 "
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