Anesthesia and the Addict

Dr Karen Murnane DNAP CRNA

Murnane Anesthesia LLC

7 October 2018

a medical disorder that affects the brain and changes behavior

Addiction

httpswwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictionpreface

Alcohol Drugs Food Sex

Types of Addiction3

Drug Addiction

bull Chronic Disease

bull Relapsing

bull Functional brain changes

bull Compulsive drug seeking

4

5

6

7

8

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

a medical disorder that affects the brain and changes behavior

Addiction

httpswwwdrugabusegovpublicationsdrugs-brains-behavior-science-addictionpreface

Alcohol Drugs Food Sex

Types of Addiction3

Drug Addiction

bull Chronic Disease

bull Relapsing

bull Functional brain changes

bull Compulsive drug seeking

4

5

6

7

8

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

Alcohol Drugs Food Sex

Types of Addiction3

Drug Addiction

bull Chronic Disease

bull Relapsing

bull Functional brain changes

bull Compulsive drug seeking

4

5

6

7

8

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

Drug Addiction

bull Chronic Disease

bull Relapsing

bull Functional brain changes

bull Compulsive drug seeking

4

5

6

7

8

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

5

6

7

8

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

6

7

8

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

7

8

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

8

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

The Opioid Epidemic

9

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

JCAHO Standards for Pain Management

bull 5th vital sign

bull Pain scales

bull Acceptable PACU pain score for discharge

bull Over prescription of opioids

10

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

Purdue Pharma and OxyContin

bull Kick-started current opioid crisis

bull Persuaded doctors to prescribe

bull lsquolsquoPartners Against Painrsquorsquo

bull Systematic effort to minimize the risk of addiction

bull rsquorsquoLess than one percentrdquo

bull Often prescribed during the perioperative period

11

NEW YORK (Reuters) - Litigation against OxyContin maker

Purdue Pharma LP is intensifying as six more US states on Tuesday announced lawsuits accusing the company of fueling a

national opioid epidemic by deceptively marketing its prescription painkillers to generate billions of dollars in sales

Pain

13

Pain

bull Multidimensional in nature

bull Injury is just one cause of pain

bull Various factors play a role in the pathogenesis of pain

bull The role of psychosocial factors

14

15

Opioids

bull Component of a balanced perioperative analgesic regimen

bull Chronic opioid exposure especially with high doses

Worsening pain control

Increased risks of opioid tolerance

Opioid-induced hypersensitivity

Medication misuse

16

Prescription psychotherapeutic users 201517

Sources of Misused Prescription Pain Relievers aged 12 or older 2015

18

ldquo34 of misused prescription opioids come from legitimate

physician medical practice officesrdquo

2015

19

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Pain

13

Pain

bull Multidimensional in nature

bull Injury is just one cause of pain

bull Various factors play a role in the pathogenesis of pain

bull The role of psychosocial factors

14

15

Opioids

bull Component of a balanced perioperative analgesic regimen

bull Chronic opioid exposure especially with high doses

Worsening pain control

Increased risks of opioid tolerance

Opioid-induced hypersensitivity

Medication misuse

16

Prescription psychotherapeutic users 201517

Sources of Misused Prescription Pain Relievers aged 12 or older 2015

18

ldquo34 of misused prescription opioids come from legitimate

physician medical practice officesrdquo

2015

19

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Pain

bull Multidimensional in nature

bull Injury is just one cause of pain

bull Various factors play a role in the pathogenesis of pain

bull The role of psychosocial factors

14

15

Opioids

bull Component of a balanced perioperative analgesic regimen

bull Chronic opioid exposure especially with high doses

Worsening pain control

Increased risks of opioid tolerance

Opioid-induced hypersensitivity

Medication misuse

16

Prescription psychotherapeutic users 201517

Sources of Misused Prescription Pain Relievers aged 12 or older 2015

18

ldquo34 of misused prescription opioids come from legitimate

physician medical practice officesrdquo

2015

19

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

15

Opioids

bull Component of a balanced perioperative analgesic regimen

bull Chronic opioid exposure especially with high doses

Worsening pain control

Increased risks of opioid tolerance

Opioid-induced hypersensitivity

Medication misuse

16

Prescription psychotherapeutic users 201517

Sources of Misused Prescription Pain Relievers aged 12 or older 2015

18

ldquo34 of misused prescription opioids come from legitimate

physician medical practice officesrdquo

2015

19

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Opioids

bull Component of a balanced perioperative analgesic regimen

bull Chronic opioid exposure especially with high doses

Worsening pain control

Increased risks of opioid tolerance

Opioid-induced hypersensitivity

Medication misuse

16

Prescription psychotherapeutic users 201517

Sources of Misused Prescription Pain Relievers aged 12 or older 2015

18

ldquo34 of misused prescription opioids come from legitimate

physician medical practice officesrdquo

2015

19

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Prescription psychotherapeutic users 201517

Sources of Misused Prescription Pain Relievers aged 12 or older 2015

18

ldquo34 of misused prescription opioids come from legitimate

physician medical practice officesrdquo

2015

19

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Sources of Misused Prescription Pain Relievers aged 12 or older 2015

18

ldquo34 of misused prescription opioids come from legitimate

physician medical practice officesrdquo

2015

19

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

ldquo34 of misused prescription opioids come from legitimate

physician medical practice officesrdquo

2015

19

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Scott EL Kroenke K Wu J et al Beneficial Effects of Improvement in Depression Pain Catastrophizing and Anxiety on Pain Outcomes A 12-Month Longitudinal Analysis J Pain 2016 17(2) 215ndash22

20

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

21

Wood TJ Thornley P Petruccelli D et al Preoperative Predictors of Pain Catastrophizing Anxiety and Depression in Patients Undergoing Total Joint Arthroplasty J Arthroplasty 2016 31(12) 2750ndash6

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Cherkin DC Sherman KJ Balderson BH et al Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain A Randomized Clinical Trial JAMA 2016 315(12) 1240ndash9

22

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Opioid Tolerance

bull US Food and Drug Administration

Use of ge 30 mg of oxycodone daily

Use 7 days or longer

bull Increased opioid dose to maintain adequate analgesia

bull May develop quickly in opioid naiumlve patients

bull Leads to higher opioid dosages

bull Increased risk of opioid-related adverse drug events

23

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Opioid-Induced Hyperalgesia

bull Increase opioid exposure leads to nociceptive sensitization

bull Neuroplastic changes both centrally and peripherally

bull Paradoxical response

bull More sensitive to certain painful stimuli

bull Any opioid

bull Acute or chronic exposure

24

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Anesthesia Management of the Opioid Tolerant Patient

25

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Perioperative Assessment

26

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

27

History of chronic pain Chronic opioid therapy

Catastrophizing Anxiety about PO pain

Female Younger age

Preoperative pain at site Pain multiple sites

Lower socioeconomic status Genetic factors

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Additional consideration

bull History of depression

bull Current or history of substance abuse

bull Risk for development of neuropathic pain

Amputations

Mastectomies

Thoracotomies

28

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Preoperative Clinic

bull Formulate perioperative analgesia plan

bull Coordinate with surgical and nursing teams

bull Perioperative education

bull Alieve anxiety

bull Manage patientrsquos expectation of pain

29

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Patient Evaluation

bull Thorough history and physical exam

bull Document the patientrsquos baseline pain

Site

Intensity

Type

Duration

30

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Carefully document medication history

bull Daily doses of short-acting and long-acting narcotics

bull Non-opioid adjunctive analgesics

bull Anxiolytics

bull Antidepressants

bull Anticonvulsants

31

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Psychiatric History

bull History of substance abuse

bull Current substance abuse

bull Depression

bull Anxiety

32

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Patient Education

bull Postoperative pain

bull Pain management options

bull Reassure that pain will be adequately treated

bull Describe typical course of postoperative pain for scheduled surgery

bull Regional anesthesia if viable option

33

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Perioperative Optimization

bull Continue regular dose of long-acting opioid medications

bull Coordinated with prescribing physician

bull Initiate preventative analgesic medications

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Chronic Medication Instructions

bull Continue up to and including day of surgery

Anxiolytics

Antidepressants

Gabapentinoids

Anticonvulsants

35

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Chronic Medication Instructions

bull Transdermal fentanyl

Continue until day of surgery

Restart post-operatively

Give equivalent dose of morphine to maintain baseline opioid level

36

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Medication Therapy for Opioid Use Disorder

37

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

The goal of medication therapy is to prevent withdrawal

symptoms

38

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

39

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

FDA Approved Medications

Methadone Buprenorphine Buprenorphine and Naltrexone Naltrexone

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Stranq J Bahor T Caulkins J et al Drug policy and the public good evidence for effective interventions Lancet 201104857610485771048578104857910485801048581104858210485831048584104858510485861048587104858810485891048590104859110485921048593104859410485951048596104859710485981048599104860010486011048602104860310486041048605104860610486071048608104860910486101048611104861210486131048614104861510486161048617104861810486191048620104862110486221048623104862410486251048626104862710486281048629104863010486311048632104863310486341048635104863610486371048638104863910486401048641104864210486431048644104864510486461048647104864810486491048650104865110486521048653104865410486551048656104865710486581048659104866010486611048662104866310486641048665104866610486671048668104866910486701048671104867210486731048674104867510486761048677104867810486791048680104868110486821048683104868410486851048686104868710486881048689104869010486911048692104869310486941048695104869610486971048698104869910487001048701104870210487032379(9810)71--83

Patients randomized to placebo withdrawal compared with

methadone or buprenorphine maintenance treatment are 2

times to 4 times more likely to be dead at a year

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Methadone

bull Full mu opioid receptor agonist

bull Has NMDA antagonist activity

bull Hepatic metabolism through cytochrome P450 system

bull Toxic dose difficult to predict

bull Has been associated with sudden cardiac death

42

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Methadone

bull Establish indication for methadone therapy

bull Confirm patients indication and home dose with methadone prescriber

bull Continue through perioperative and postoperative periods

bull Manage acute pain with immediate-release opioids

bull If unable to take oral dose given IV methadone

43

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

44

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Buprenorphine

bull FDA approval

Acute pain

Chronic pain

Opioid use disorder

bull Schedule III controlled drug

bull Multiple routes

bull Multiple durations

45

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Buprenorphine

bull Opioid receptor agonist and antagonist

bull Mu receptor agonist

High affinity

Partial activation

bull ORL-1 receptor antagonist

bull Kappa receptor antagonist

46

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Buprenorphine

Preoperative

bull Continue daily dose

bull Document buprenorphine providerrsquos contact information

Day of Surgery

bull Usual daily dose

bull Plan for multimodal pain management

47

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Buprenorphine perioperative use

bull Optimal use in the perioperative setting has not be established

bull Continue preoperatively

bull Opioid selection not studied

bull Consider opioids with higher mu affinity

Sufentanil

Fentanyl

Hydromorphone

48

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

49

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Buprenorphine perioperative use

bull Buprenorphine has been used as primary opioid

bull Stopping buprenorphine preoperative

Medically risk

Discomfort

Significant opioid debt

Consult prescriber to assist with restarting

50

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Buprenorphine

bull Some advocate to discontinue 2-3 days prior to surgery

bull Bridge therapy with pure opioid agonist

bull Likely to require higher doses of opioids

bull Multimodal analgesia

bull Regional anesthesia when appropriate

51

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Naltrexone

bull Semisynthetic opioid antagonist derived from oxymorphone

bull Competitive antagonist at mu opioid receptors

bull Partial agonist at kappa receptors

bull Oral or parenteral dosing

52

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Naltrexone

bull Oral formulation

Peak concentration at 1 hour

Half-life is approximately 10 hours

bull XR-NXT

Biodegradable microsphere matrix embedded with naltrexone

Peaks in 7 days

Opioid antagonist effects of XR-NXT decrease over the course of a month

53

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Naltrexone perioperative use

bull Close coordination with the patient and prescribing physician

bull Oral naltrexone should be discontinued 5 half-lives preoperatively

bull XR-NXTmdashlittle guidance

Complete lack of analgesia to opioids in the first 2 weeks

Successful pain management has been reported starting in the 4th week

Close monitoring may be required however if patients receive opioids postoperatively

bull Restarting naltrexone requires patients to be free of opioids to avoid acute withdrawal

54

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

55

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Key points

bull Buprenorphine and methadone for the treatment of opioid use disorder should be continued in the perioperative period for most patients

bull Oral naltrexone should be discontinued 2 days before surgery and resumed once additional opioids are no longer needed

bull Extended-release injectable naltrexone is active for 28 days with peak at 7 days

bull Multimodal pain management is critical for patients on chronic opioid therapy

56

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Intraoperative Management

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

New Paradigm for

Analgesia Management

58

Koepke EJ Manning EL Miller TM et al The Rising Tide of Opioid Use and Abuse The Role of the Anesthesiologist Perioper Med 2018 3(7)5

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

The ASA Task Force on Acute Pain Management in 2012

Multimodal pain management should be included for the

management of perioperative pain whenever possible

59

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Multimodal Analgesia Medications

bull Acetaminophen

bull NSAIDs

bull Calcium channel α-2-δ antagonists

bull Steroids

bull α-2-agonists

bull N-methyl-D-aspartate (NMDA) receptor antagonists

bull Magnesium

bull Lidocaine

bull Esmolol

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Uncontrolled Postoperative Pain

bull Linked with multiple complications

bull Risk factor for developing chronic postoperative pain

bull Can lead to increased healthcare spending and reduced quality of life

bull Significant driver of patient dissatisfaction

bull Multimodal analgesia should continue postoperatively

61

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

62

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

NSAIDs

bull Decrease opioid consumption by 25ndash30

bull Superior analgesia when combined with opioids

bull First-line medications for mild-to-moderate pain

bull Side effects

63

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Acetaminophen

bull Non-opioid antipyretic analgesic

bull Additive but not necessarily synergistic effect when combined with NSAIDs

bull Lacks significant anti-inflammatory activity

bull Use as a scheduled dose

bull Use in combination with NSAIDs

64

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

NMDA

bull Important part because of its role in central sensitization

bull Ketamine

bull Magnesium

bull Methadone

65

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Calcium channel α-2-δ antagonists

bull Reduce neuronal excitability

bull Gabapentin

bull Pregabalin

bull Neuromodulators

66

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Dexamethasone

bull Reduce pain

bull Decrease opioid use

bull Reduced early and late pain at rest and movement

bull Intermediate dose 011ndash02 mgkg

bull Preoperative administration most efficacious

67

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Dexmedetomidine

bull a2-adrenergic receptor agonist

bull Sedative anxiolytic

bull Sympatholytic

bull Analgesic

bull Decreases pain intensity

bull Reduce the need for opioids

68

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Esmolol

bull ultrandashshort-acting b1-receptor antagonist

bull Intraoperative use

bull Decreases intraoperative and postoperative opioid consumption

69

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70

Regional Anesthesia

bull Reduce or eliminate the need for opioids

bull Continuous infusion of local anesthetics

bull Field blocks

bull Additives

70