Clinicians unfamiliar with caring for opioid-tolerant patients are likely to be fearful of the high doses often required by patients who are opioid tolerant, and as a result, the patient may be underdosed. Tolerance to the adverse effects of opioids develops more rapidly than to analgesia, meaning that opioids may be safely titrated to relatively high doses to provide adequate analgesia (Mehta & Langford, 2006). It is important for clinicians to appreciate that although opioid tolerant patients may require higher opioid doses than opioid naïve patients, they are not immune to opioid-induced respiratory depression. All patients are at risk for this adverse event (Jarzyna et al., 2011).
Unfortunately, there are no evidence-based guidelines for predicting postoperative opioid requirements on the basis of the opioid dose consumed before surgery. One suggestion is to expect opioid requirements postoperatively in the opioid-tolerant patient to be two to four times the dose required in an opioid-naïve person (Carroll, Angst, & Clark, 2004). One prospective study showed opioid tolerant patients required nearly seven times more opioid than opioid naïve patients (Patanwala, Jarzyna, Miller, & Erstad, 2008); however, individualization of care is essential to ensure effective pain control and patient safety (Pasero, Quinn, Portenoy, McCaffery, & Rizos, 2011). Multi-disciplinary and multi-faceted approaches to overcome barriers to the provision of the best possible pain relief for opioid tolerant patients have been shown to be effective (Doi, Shimoda, & Gibbons, 2014; Dykstra, 2012).