OUD Screening Tools
The pervasive stigma surrounding Opioid Use Disorder (OUD) significantly impacts the reporting and identification of this condition, particularly in the preoperative period. Many patients may be reluctant to disclose their opioid use or misuse due to fear of judgment, potentially leading to underreporting and insufficient awareness of their condition by healthcare providers. This underreporting poses serious challenges, as proper identification of OUD is crucial for planning an appropriate and safe intraoperative strategy. Without accurate information on a patient’s opioid use, healthcare providers may be unable to adequately prepare for potential complications or to tailor anesthesia and pain management strategies effectively.
To address this issue and facilitate more accurate identification of OUD, specific screening tools have been developed. The OWLS, a four-item screen (Overuse, Worrying, Losing interest, Sluggishness) validated for identifying prescription opioid use disorder in primary care, is one such instrument. By assessing these behaviors, the OWLS tool provides a structured way for clinicians to gather information and evaluate a patient’s risk of opioid misuse. Another valuable tool in this context is the COMM (Current Opioid Misuse Measure), which is specifically designed to identify opioid use disorder. The COMM assesses a variety of factors related to a patient’s current opioid use, helping to distinguish between appropriate use and misuse.
By employing these and other screening tools, healthcare providers can gain a clearer understanding of a patient’s relationship with opioids, ultimately contributing to more informed and safer clinical decision-making. However, the effectiveness of these tools depends on the willingness of patients to provide honest responses, highlighting the need for supportive and nonjudgmental communication to overcome the stigma and encourage accurate reporting. In this way, the combination of effective screening tools and a compassionate approach to patient care can play a critical role in improving the identification and management of OUD in the preoperative setting.
Anesthetic Considerations of Medications for OUD (MOUD)
Anesthetic management of patients undergoing surgery who are on Medications for Opioid Use Disorder (MOUD) requires careful consideration of the pharmacological properties of these medications and their interactions with anesthetic agents. Buprenorphine, a partial mu agonist and kappa antagonist, is one such medication. It has a high affinity for the mu receptor, and it is recommended to continue buprenorphine before surgery. In some cases, rather than supplementing with additional opioid analgesics, increasing the dose of buprenorphine itself may be more beneficial, though this should be determined on a case-by-case basis.
Naltrexone, a competitive mu and kappa antagonist, presents different challenges. For patients on oral naltrexone, it is advised to discontinue the medication 72 hours prior to surgery if moderate to severe surgical pain is expected. For those on extended-release injectable naltrexone, a longer discontinuation period of 30 days is recommended under the same circumstances. However, if the anticipated surgical pain is mild and can be managed with non-opioid modalities, continuation of naltrexone is suggested to minimize the risk of relapse.
Methadone, a full mu agonist, is another medication used in the treatment of OUD. Current practice recommendations have undergone major revisions, advocating for the continuation of methadone prior to surgery. In certain cases, like with buprenorphine, it might be more appropriate to increase the dose of methadone rather than adding additional opioids for analgesia. Any decisions regarding discontinuation or dose adjustment of MOUD should be made on an individual basis and involve thorough discussion and coordination between anesthesia, surgical, and addiction treatment providers. This collaborative approach ensures that the unique needs of patients on MOUD are adequately met, promoting optimal surgical outcomes while minimizing the risk of opioid-related complications and relapse.
| Medication | Receptor activity | Perioperative recommendation |
|---|---|---|
| Buprenorphine | Partial mu agonist, kappa antagonist, high mu affinity | Continue before surgery; increasing the buprenorphine dose may serve better than adding other opioids |
| Naltrexone, oral | Competitive mu and kappa antagonist | Discontinue 72 hours before surgery if moderate to severe surgical pain is expected |
| Naltrexone, extended-release injectable | Competitive mu and kappa antagonist | Discontinue 30 days before surgery if moderate to severe surgical pain is expected |
| Naltrexone, either form, mild expected pain | Competitive mu and kappa antagonist | Continue if pain can be managed with non-opioid modalities, to minimize relapse risk |
| Methadone | Full mu agonist | Continue before surgery; increasing the methadone dose may be more appropriate than adding other opioids |
Preoperative PO Multimodal Drugs to Consider
In the preoperative setting, implementing a multimodal approach to pain management is crucial to optimize patient outcomes and minimize reliance on opioids. Non-steroidal anti-inflammatory drugs (NSAIDs) play a pivotal role in this regard. Ibuprofen, with a recommended dose of 600 mg, has been shown to be as efficacious as 15 mg of oxycodone, with a maximum daily limit set at 3200 mg. Celecoxib, another NSAID, is recommended at 400 mg for patients below 65 years of age, and at 200 mg for those above 65. However, caution is advised when prescribing NSAIDs to patients with bleeding disorders, cardiac disease, or renal disease due to the associated risks.
Acetaminophen is another integral component of multimodal pain management, with a recommended dose range of 975-1000 mg and a maximum daily limit of 3000 mg. It is imperative to exercise caution in patients with liver failure when administering acetaminophen due to its hepatotoxic potential.
Gabapentinoids, such as pregabalin and gabapentin, have also found their place in preoperative pain management. Pregabalin is recommended at 25-50 mg orally, while gabapentin is suggested at 300-1200 mg, with a reduced dose of 100-300 mg for patients above 65 years of age or those with renal impairment. However, it is vital to be vigilant about the potential for abuse and the risk of respiratory depression associated with gabapentinoids.
Skeletal muscle relaxants like methocarbamol can be considered, with a recommended intravenous dose of 0.5-1 g or an oral dose of 500-750 mg for patients 65 years of age or below, ensuring not to exceed 3 g/day for more than 3 days. Caution is advised in patients with renal issues, seizure disorders, and it is generally recommended to avoid use in patients above 65 years of age.
In summary, a preoperative multimodal approach to pain management that includes NSAIDs, acetaminophen, gabapentinoids, and skeletal muscle relaxants can provide effective pain relief while mitigating the risks associated with opioid use. However, it is imperative to tailor the regimen to each patient's specific needs and medical history, exercising caution in those with associated comorbidities.
