Abstract
The opioid epidemic has ushered in a high-risk patient population that all pain physicians will encounter in the inpatient setting. With the increased emphasis on pain as the “fifth vital sign” and a wider array of new opioids, the 1990s marks the beginning of a dramatic rise in opioid prescriptions. Opioid analgesics are the most commonly prescribed medication in the United States. Additionally, ten million people in the United States use opioid prescriptions for nonmedical reasons (Raub and Vettese, J Hosp Med 12:375–379, 2017). Chronic opioid users exhibit signs of tolerance to opioids while also having increased perception of pain. Acute pain management in these patients is best managed by a multimodal approach using medications such as ketamine, lidocaine infusions, dexmedetomidine and regional anesthetic techniques.
More than two million of the opioid users meet criteria for opioid use disorder (OUD) (Ward et al., Anesth Analg 127:539–547, 2018). OUD is characterized by pronounced craving and preoccupation for opioids, inability to refrain from using, and escalation of use despite negative consequences. Although there are currently three FDA-approved medications to treat OUD (methadone, buprenorphine, and extended-release injectable naltrexone) only about 20% with OUD are on one of these medications (Ward et al., Anesth Analg 127:539–547, 2018). Pain physicians must be well-versed in how to manage these medications in the setting of acute pain and use clinical judgment to distinguish subjective pain from drug-seeking presentations. All OUD patients benefit from early psychiatric intervention to best address patient needs. For the roughly 80% of OUD patients not on medication for opioid use disorder (MOUD), this includes the opportunity to start one of the three medications while in the inpatient setting. Discharge planning for these patients is critical and relapse risk is best mitigated by providing adequate analgesia and connecting with outpatient substance use treatment. All patients discharged on daily opioid dosing greater than 90-mg morphine equivalents, those on longer-acting opioids (methadone or oxycodone), and those with a history of OUD or substance misuse should be discharged with intranasal naloxone kits.
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References
Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health. Center for Behavioral Health Statistics and Quality; 2019. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf. Accessed 10 Sept 2019.
Herron A, Brennan T. The ASAM essentials of addiction medicine, vol. 1. 2nd ed. Philadelphia: Wolters Kluwer; 2015. p. 9–35, 12:535–565.
Handelsman L, Cochrane K, Aronson M, Ness R, Rubinstein K, Kanof P. Two new rating scales for opiate withdrawal. Am J Drug Alcohol Abuse. 1987;13:293–308.
The use of opioids for the treatment of chronic pain. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain. 1997;13(1):6–8.
Lanser P, Gesell S. Pain management: the fifth vital sign. Health Benchmarks. 2001;8:68–70.
Atluri S, Sudarshan G, Manchikanti L. Assessment of the trend in the medical use and misuse of opioid analgesics from 2004 to 2011. Pain Physician. 2014;17:E119–28.
Manchikanti L, Kaye A, Kaye A. Current state of opioid therapy and abuse. Curr Pain Headache Rep. 2016;20:34.
Freye E, Levy J. Opioids in medicine: a comprehensive review on the mode of action and the use of analgesics in different clinical pain states. Amsterdam: Springer; 2008.
Zubieta J. Regional mu opioid receptor regulation of sensory and affective dimensions of pain. Science. 2001;293:311–5.
Pattison K. Opioids and the control of respiration. Br J Anaesth. 2008;100:747–58.
Volkow N, McLellan A. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016;374:1253–63.
Butler S, Black R, Cassidy T. Abuse risks and routes of administration of different prescription opioid compounds and formulations. Harm Reduct J. 2011;8:29.
Wax P, Ruha A. Withdrawal syndromes and opioid withdrawal. In: Irwin R, Rippe J, editors. Irwin and Rippe’s intensive care medicine. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 1707–16.
Kosten T, George T. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1:13–20.
Roeckel L, LeCoz G, Gaveriauz-Ruff C, Simonin F. Opioid-induced hyperalgesia: cellular and molecular mechanisms. Neuroscience. 2016;338:160–82.
American Psychiatric Association, editor. Diagnostic and statistical manual of mental disorders. 5th ed. Washington: American Psychiatric Association; 2013.
Volkow N, Morales M. The brain on drugs: from reward to addiction. Cell. 2015;162:712–25.
Ewan E, Martin T. Analgesics as reinforcers with chronic pain: evidence from operant studies. Neurosci Lett. 2013;557:60–6.
Koob G, Volkow N. Neurocircuitry of addiction. Neuropsychopharmacology. 2010;35:217–38.
Cicero T, Ellis M. Understanding the demand side of the prescription opioid epidemic: does the initial source of opioids matter? Drug Alcohol Depend. 2017;173:S4–S10.
Centers for Disease Control and Prevention. Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths—United States, 2010. Morb Mortal Wkly Rep. 2014;63:881–8.
Madadi P, Persaud N. Suicide by means of opioid overdose in patients with chronic pain. Curr Pain Headache Rep. 2014;18:460.
Oquendo M, Volkow N. Suicide: a silent contributor to opioid overdose deaths. N Engl J Med. 2018;378:1567–9.
Miller M, Barber C, Leatherman S, Fonda J, Hermos J, Cho K, Gagnon D. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015;175:608–15.
Cheatle M. Depression, chronic pain, and suicide by overdose: on the edge. Pain Med. 2011;12:S43–8.
Tintinalli J, Stapczunski J, Ma O, Yealy D, Meckler G, Cline D. Tintinalli’s emergency medicine: a comprehensive study guide. 8th ed. New York: McGraw-Hill Education; 2016.
Centers for Disease Control and Prevention. Number of poisoning deaths involving opioid analgesics and other drugs or substances—United States, 1999-2010. Morb Mortal Wkly Rep. 2013;62:234.
Alford D. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144:127–34.
Merrill J, Rhodes L, Deyo R, Marlatt G, Bradley K. Mutual mistrust in the medical care of drug users: the keys to the “narc” cabinet. J Gen Intern Med. 2002;17:327–33.
Screening/SAMHSA-HRSA. In: Integration.samhsa.gov. 2019. https://www.integration.samhsa.gov/clinical-practice/sbirt/screening. Accessed 30 July 2019.
Webster L, Webster R. Predicting aberrant behaviors in opioid-treated patients: preliminary risk tool. Pain Med. 2005;6:432–42.
Brown R, Rounds L. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wis Med J. 1995;94:135–40.
Babor T, McRee B, Kassebaum P, Grimaldi P, Ahmed K, Bray J. Screening, brief intervention, and referral to treatment (SBIRT). Subst Abus. 2017;28:7–30.
D’Onofrio G, O’Connor P, Pantalon M, Chawarski M, Busch S, Owens P, Bernstein S, Fiellin D. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized controlled trial. JAMA. 2015;313:1636–44.
Savage S. Principles of pain treatment in the addicted patient. Principles of addiction medicine. 2nd ed. Chevy Chase: American Society of Addiction Medicine; 1998. p. 919–46.
Peng P, Tumber P, Gourlay D. Review article: perioperative pain management of patients on methadone therapy. Can J Anesth. 2005;52(5):513–23.
Mattick R, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2008;16:CD002207. https://doi.org/10.1002/14651858.CD002207.pub3.
Dutra L, Stathopoulou G, Basden S, Leyro T, Powers M, Otto M. A meta-analytic review of psychosocial interventions for substance use disorders. Am J Psychiatry. 2008;165:179–87.
Raub J, Vettese T. Acute pain management in hospitalized adult patients with opioid dependence: a narrative review and guide for clinicians. J Hosp Med. 2017;12:375–9.
Coluzzi F, Bifulco F, Cuomo A, Dauri M, Leonardi C, Melotti R, Natoli S, Romualdi P, Savoia G, Corcione A. The challenge of perioperative pain management in opioid-tolerant patients. Ther Clin Risk Manag. 2017;13:1163–73.
Kim D, Patel A, Sibai N. Conversion of intrathecal opioids to fentanyl in chronic pain patients with implantable pain pumps: a retrospective study. Neuromodulation. 2019;22:823–7. https://doi.org/10.1111/ner.12936.
Weaver J. Multiple risks for patients using the transdermal fentanyl patch. Anesth Prog. 2014;61:1–2.
Frölich M, Giannotti A, Modell J. Opioid overdose in a patient using a fentanyl patch during treatment with a warming blanket. Anesth Analg. 2001;93:647–8.
Thompson J, Rowbotham D. Pharmacokinetics of transdermal fentanyl. Anesth Analg. 2002;95:781.
U.S Department of Justice Drug Enforcement Administration. 2018 National Drug Threat Assessment; 2018. https://www.dea.gov/sites/default/files/2018-11/DIR-032-18%202018%20NDTA%20%5Bfinal%5D%20low%20resolution11-20.pdf. Accessed 18 Sept 2019.
Ward E, Quaye A, Wilens T. Opioid use disorders. Anesth Analg. 2018;127:539–47.
Cornett E, Kline R, Robichaux S, Green J, Anyama B, Gennuso S, et al. Comprehensive perioperative management considerations in patients taking methadone. Curr Pain Headache Rep. 2019;23(7):49.
Harrison T, Kornfeld H, Aggarwal A, Lembke A. Perioperative considerations for the patient with opioid use disorder on buprenorphine, methadone, or naltrexone maintenance therapy. Anesthesiol Clin. 2018;36:345–59.
Schwenk E, Viscusi E, Buvanendran A, Hurley R, Wasan A, Narouze S, et al. Consensus guidelines on the use of intravenous ketamine infusions for acute pain management from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists. Reg Anesth Pain Med. 2018;43:456–66.
Jouguelet-Lacoste J, La Colla L, Schilling D, Chelly J. The use of intravenous infusion or single dose of low-dose ketamine for postoperative analgesia: a review of the current literature. Pain Med. 2015;16:383–403.
Dunn L, Durieux M. Perioperative use of intravenous lidocaine. Anesthesiology. 2017;126:729–37.
Weibel S, Jokinen J, Pace N, Schnabel A, Hollmann M, Hahnenkamp K, et al. Efficacy and safety of intravenous lidocaine for postoperative analgesia and recovery after surgery: a systematic review with trial sequential analysis. Br J Anaesth. 2016;116(6):770–83.
De Oliveira G, Almeida M, Benzon H, McCarthy R. Perioperative single dose systemic dexamethasone for postoperative pain. Anesthesiology. 2011;115:575–88.
Polderman J, Farhang-Razi V, Dieren S, Kranke P, DeVries J, Hollmann M, Preckel B, Hermanides J. Adverse side-effects of dexamethasone in surgical patients—an abridged Cochrane systematic review. Anaesthesia. 2019;74:929–39.
Low Y, White W, Habib A. Postoperative hyperglycemia after 4- vs 8-10-mg dexamethasone for postoperative nausea and vomiting prophylaxis in patients with type II diabetes mellitus: a retrospective database analysis. J Clin Anesth. 2015;27(7):589–94.
Wenzel J, Schwenk E, Baratta J, Viscusi E. Managing opioid-tolerant patients in the perioperative surgical home. Anesthesiol Clin. 2016;34:287–301.
Gelineau A, King M, Ladha K, Burns S, Houle T, Anderson T. Intraoperative esmolol as an adjunct for perioperative opioid and postoperative pain reduction. Anesth Analg. 2018;126:1035–49.
Kampman K, Jarvis M. American Society of Addiction Medicine National Practice Guidelines for the use of medications in the treatment of addiction involving opioid use. J Addict Med. 2015;9(5):358–67.
Substance Abuse and Mental Health Services Administration. SAMHSA opioid overdose prevention toolkit. HHS publication no. (SMA) 18-4742. Substance Abuse and Mental Health Services Administration; 2018.
Wesson D, Ling W. The clinical opioid withdrawal scale (COWS). J Psychoactive Drugs. 2003;35:253–9.
Sigmon S, Bisaga A, Nunes E, O’Connor P, Kosten T, Woody G. Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice. Am J Drug Alcohol Abuse. 2012;38:187–99.
Collins E, Kleber H, Whittington R, Heitler N. Anesthesia-assisted vs buprenorphine or clonidine-associated heroin detoxification and naltrexone induction: a randomized trial. JAMA. 2005;294:903–13.
Palepu A, Tyndall M, Leon H, Muller J, O’Shaughnessy M. Hospital utilization and costs in a cohort of injection drug users. CMAJ. 2001;164(4):415–20.
O’Toole T, Conde-Martel A, Young J, Price J, Bigelow G, Ford D. Managing acutely ill substance-abusing patients in an integrated day hospital outpatient program: medical therapies, complications, and overall treatment outcomes. J Gen Intern Med. 2006;21(6):570–6.
Wei J, Defries T, Lozada M, Young N, Huen W, Tulsky J. An inpatient treatment and discharge planning protocol for alcohol dependence: efficacy in reducing 30-day readmissions and emergency department visits. J Gen Intern Med. 2015;30(3):365–70.
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Mainkar, O., Greiner, M., Avery, J., Mehta, N. (2020). Inpatient Pain Management in Patient with Opioid Use Disorder. In: Abd-Elsayed, A. (eds) Guide to the Inpatient Pain Consult. Springer, Cham. https://doi.org/10.1007/978-3-030-40449-9_13
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