Caring for Our Patients With Opioid Use Disorder in the Perioperative Period

A Guide for the Anesthesiologist

Antje M. Barreveld, MD; Andrew Mendelson, DO; Brittany Deiling, DO; Catharina A. Armstrong, MD, MPH; Eugene R. Viscusi, MD; Lynn R. Kohan, MD

Disclosures

Anesth Analg. 2023;137(3):488-507.

Abstract and Introduction

Abstract

Opioid use disorder (OUD) is a rising public health crisis, impacting millions of individuals and families worldwide. Anesthesiologists can play a key role in improving morbidity and mortality around the time of surgery by informing perioperative teams and guiding evidence-based care and access to life-saving treatment for patients with active OUD or in recovery. This article serves as an educational resource for the anesthesiologist caring for patients with OUD and is the second in a series of articles published in Anesthesia & Analgesia on the anesthetic and analgesic management of patients with substance use disorders. The article is divided into 4 sections: (1) background to OUD, treatment principles, and the anesthesiologist; (2) perioperative considerations for patients prescribed medications for OUD (MOUD); (3) perioperative considerations for patients with active, untreated OUD; and (4) nonopioid and nonpharmacologic principles of multimodal perioperative pain management for patients with untreated, active OUD, or in recovery. The article concludes with a stepwise approach for the anesthesiologist to support OUD treatment and recovery. The anesthesiologist is an important leader of the perioperative team to promote these suggested best practices and help save lives.

Introduction

Opioid use disorder (OUD), though a treatable disease, is an intensifying public health crisis in the United States and worldwide. From 2020 to 2021, drug overdose deaths increased by nearly 30% versus the same period in the year prior.^[1] The anesthesiologist may not view him or herself as a key leader in improving access to life-saving treatment for OUD. However, as leaders of perioperative medicine, the anesthesiologist is essential to guiding OUD treatment, a critical step to improving our patients' morbidity and mortality around the time of surgery. This public health crisis must be addressed head on by all health care providers. Anesthesiologists can play a leading role in identifying patients with untreated OUD to appropriately direct the anesthetic and perioperative planning, as well as facilitate patient access to OUD treatment.^[2,3] Studies demonstrate that even brief medication courses initiated in the emergency department or inpatient setting decrease morbidity and mortality.^[4–10] Despite clear evidence-based strategies, most individuals with OUD are not receiving treatment.^[11–13] Given the millions of patients and families impacted by this devastating disease, anesthesiologists do not need to be experts in addiction medicine but rather can help guide OUD treatment and reverse these trends. Recovery, and maintaining recovery, is possible.

This article is the second in a series of articles published in Anesthesia & Analgesia on the anesthetic and analgesic management of patients with substance use disorders (SUDs). Anesthesiologists may defer recommending treatment strategies or medications for OUD (MOUD) due to a lack of knowledge and/or guiding principles. This article aims to address this barrier. Designed to provide a practical framework on basic strategies for the general anesthesiologist in suggested best practices for team-based perioperative management of patients with OUD or in recovery, this publication is not intended to be an exhaustive review. The manuscript is divided into 4 sections: (1) overview of key background information on OUD, a disease with significant public health, psychosocial, and economic consequences, as well as a brief review of multidisciplinary treatment strategies including MOUD; (2) perioperative considerations and best practices for the anesthesiologist in caring for our patients prescribed 1 of the 3 Food and Drug Administration (FDA)-approved MOUD (methadone, buprenorphine, or naltrexone); (3) best practices in the perioperative management of patients with active, untreated OUD and considerations for comanaging postoperative pain and addiction; and (4) principles in nonopioid and nonpharmacologic perioperative pain management strategies for patients with OUD. The article concludes with a stepwise approach for the anesthesiologist to support treatment and recovery—a positive impact on our patients' health and postsurgical outcomes.

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Table 1. American Psychiatric Association Criteria for OUD
Impaired control	Social impairment	Risky use	Pharmacological criteria
1. Taking larger amounts or taking drugs over a longer period than intended.	5. Problems fulfilling obligations at work, school, or home.	8. Using opioids in physically hazardous situations.	10. Tolerance (ie, need for increased amounts or diminished effect with continued use of the same amount).
2. Persistent desire or unsuccessful efforts to cut down or control opioid use.	6. Continued opioid use despite having recurring social or interpersonal problems.	9. Continued opioid use despite ongoing physical or psychological problems likely to have been caused or worsened by opioids.	11. Experiencing withdrawal (opioid withdrawal syndrome) or taking opioids (or a closely related substance) to relieve or avoid withdrawal symptoms.
3. Spending a great deal of time obtaining or using the opioid or recovering from its effects.	7. Giving up or reducing activities because of opioid use.
4. Craving, or a strong desire or urge to use opioids

OUD can be classified by severity according to the number of criteria met: mild (2–3 criteria); moderate (4–5 criteria); severe (6 or more criteria).¹⁶
Abbreviation: OUD, opioid use disorder.

Table 2. Comparison of the 3 FDA-Approved Medications for OUD Treatment
	Methadone	Buprenorphine	Naltrexone
Mechanism of action	Full agonist at μ-opioid receptor	Partial agonist at μ-opioid receptor	Antagonist at μ-opioid receptor
Dosing average range	80 to 100 mg PO daily	4 to 24 mg SL/PO daily	380 mg IM depot injection 50 mg PO daily
Setting	Licensed OTP	Any medical setting X-waiver no longer required	Any medical setting
Advantages	Care provided in highly structured supervised setting with built-in resources Use in comorbid pain management Low diversion	Care provided in a variety of outpatient models; less structured then OTP Lower risk of overdose Use in comorbid pain management Dosing flexibility	Low diversion Not an opioid Improved compliance No physical dependence Verifiable dosing Less stigma
Disadvantages	Caution with QTc prolongation Adverse effects: may increase LFTs, constipation, and other opioid-related side effects Caution with increased overdose risk Withdrawal with abrupt cessation	Diversion possible Adverse effects: constipation and other opioid-related side effects Withdrawal with abrupt cessation	Cannot be used for comorbid pain management Adverse effects: flu-like symptoms at first injection Requires ~10-d opioid-free period before initiation to avoid precipitated withdrawal

Adapted from the work of Blanco and Volkow⁴⁸ and Bell and Strang.⁵⁴
Abbreviations: FDA, Food and Drug Administration; IM, intramuscular; LFTs, liver function tests; OTP, outpatient treatment program; OUD, opioid use disorder; PO, per os (oral); SL, sublingual.

Table 3. Opioid Withdrawal Management Pharmacologic Treatments
Opioid medications^a	Symptom-directed medications
Buprenorphine—may be preferred over methadone to facilitate discharge planning	Loperamide—diarrhea Promethazine, prochlorperazine, ondansetron—nausea or vomiting Dicyclomine—abdominal cramping
Methadone	NSAIDs—myalgias Acetaminophen—myalgias Clonidine—autonomic symptoms Tizanidine—autonomic symptoms Trazodone—sleeplessness

Abbreviations: COWS, Clinical Opiate Withdrawal Scale; NSAID, nonsteroidal anti-inflammatory drug.
^aTitrate to effect using available order sets or dosing protocols and withdrawal scales (eg, COWS).

Table 4. Perioperative Considerations for the Patient With Active, Untreated OUD
Perioperative considerations	Action steps
Preoperative considerations
Substance use history	Identify substances used, frequency of use, last known use, quantity, and any reported consequences of use
Review of systems	Identify any comorbid health conditions, infections, etc
Physical examination	Evaluate for signs of acute intoxication (eg, slurred speech, sedation/head nodding, miosis, etc) Evaluate for SUD stigmata (eg, infected skin, visible injection sites, etc) Evaluate for signs of withdrawal (agitation, vomiting, nausea, shivering, etc) Perform full physical to examine for cardiopulmonary or other active medical issues Dental examination for dental decay
Past anesthetic review	Identify any prior anesthetic complications
Diagnostic testing (as indicated on case-by-case basis)	Possible laboratory studies to obtain: LFTs Renal function Coagulation tests Infectious disease markers/studies Urine drug screen Pregnancy test Other diagnostics: EKG, echocardiogram, etc as indicated
Patient counseling and care coordination	Coordinate perioperative care with surgical team; consider delaying elective surgery to pursue treatment as indicated Discuss pain management plan and expectations with patient and surgical team
Intraoperative considerations
Gastrointestinal	Implement aspiration precautions as indicated (eg, delayed gastric emptying, active vomiting, etc) Avoid nasal gastric tube if inhaled/nasal route used for illicit opioid or other substances
Airway	Monitor routinely for bronchial spasticity or secretions
Pulmonary	Ensure adequate preoxygenation If acute intoxication or recent overdose, monitor for pulmonary edema and ensure airway protection
Cardiac	If opioid withdrawal: monitor for sympathetic stimulation, hypertensive crisis, signs of cardiac ischemia or myocardial infarction, etc and manage accordingly If opioid overdose: monitor for increased risk of ischemia, heart failure, cardiac arrhythmias, etc and manage accordingly
Renal	Caution with renal insufficiency and dose medications appropriately
Infectious disease	Monitor for infection or signs of sepsis; treat hemodynamic instability as indicated; administer appropriate antibiotic therapy Ensure universal precautions
Anesthetic considerations	Caution with increased risk of respiratory depression with benzodiazepines Anesthetic requirements may be increased or decreased (if acutely intoxicated)
Pain management considerations	Maximize multimodal strategies (see Table 5) Opioids may be dosed as indicated but may be ineffective due to tolerance Consider hyperalgesia with high-dose illicit or administered opioids
Postoperative considerations
Pain management	Coordinate pain management plan with surgical team Maximize nonopioid strategies Consider recommending buprenorphine initiation
Withdrawal management	Manage withdrawal symptoms supportively with buprenorphine or methadone or other pharmacologic therapies (see Table 3)

Abbreviations: EKG, electrocardiogram; LFTs, liver function tests; OUD, opioid use disorder; SUD, substance use disorder.

Table 5. Nonopioid Principles of Multimodal Perioperative Pain Management for Patients With Active, Untreated OUD or in Recovery
Preoperative	Intraoperative	Postoperative
Provide preoperative education Manage patient expectations and coordinate shared decision-making with the patient on OUD treatment goals Consider preoperative pain or addiction consultation Coordinate care with MOUD provider or consider referral for OUD treatment Involve family/support person, peer support, behavioral or counseling support as indicated Optimize nutrition/hydration	Nonopioid medications Ketamine Lidocaine Infusion Acetaminophen NSAIDs Gabapentinoids Magnesium Dexmedetomidine Esmolol Muscle relaxants Local infiltration by surgical team Regional anesthesia techniques Spinal opioid injection (morphine/hydromorphone) Epidural catheter (local anesthetic ± opioid) Peripheral nerve block (single shot versus continuous catheter)	COWS monitoring and medications to treat opioid withdrawal symptoms (see Table 3) Acute pain service and addiction medicine consultation when available Nonpharmacologic Mindfulness training Cognitive behavioral therapy Support groups (eg, narcotics anonymous) 12-step group therapy Relaxation strategies/"apps" Acupuncture Topicals (ice, lidocaine ointment, and lidocaine patches) Discharge planning with MOUD provider Education and harm reduction strategies, overdose prevention education, nasal naloxone prescription

Abbreviations: COWS, Clinical Opiate Withdrawal Scale; MOUD, medications for opioid use disorder; NSAIDs, nonsteroidal anti-inflammatory drugs; OUD, opioid use disorder.