Table 56-15
- Preoperative
- Evaluation: Early recognition and high index of suspicion.
- Identification: Identify factors such as total opioid dose requirement and previous surgery or trauma.
- Consultation: Meet with addiction specialists and pain specialists for perioperative planning.
- Reassurance: Discuss patient concerns related to pain control, anxiety, and risk of relapse.
- Medication: Calculate the opioid dose requirement and modes of administration; provide anxiolytics as needed.
- Intraoperative
- Maintain baseline opioids (oral, transdermal, intravenous).
- Increase the intraoperative and postoperative opioid dose to compensate for tolerance. Provide peripheral neural or plexus blockade (consider neuraxial techniques).
- Use nonopioids as analgesic adjuncts.
- Postoperative
- Plan preoperatively for postoperative analgesia (include an alternative).
- Maintain baseline opioids.
- Use multimodal analgesic techniques.
- Use patient-controlled analgesia (use as primary therapy or as supplementation for neuraxial techniques).
- Continue neuraxial opioids.
- Continue continuous neural blockade.
- After Discharge
- If surgery provides complete pain relief, opioids should be tapered rather than abruptly discontinued.
- Develop a pain management plan before hospital discharge (provide adequate doses of opioid and nonopioid analgesics).