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Brief review: Perioperative management of the patient with chronic non-cancer pain

[Article de synthèse court : Prise en charge periopératoire des patients souffrant de douleur chronique non cancéreuse]

Ibrahim Hadi, MD FRCPC^*, Patricia K. Morley-Forster, MD FRCPC^*, Steven Dain, MD FRCPC^*, Kim Horrill, RN MScN ACNP and Dwight E. Moulin, MD FRCPC

^* From the Department of Anesthesia and Perioperative Medicine,
School of Nursing, Faculty of Health Sciences, and the
Departments of Oncology and Clinical Neurological Sciences, Interdisciplinary Pain Program, University of Western Ontario, London, Ontario, Canada.

Address correspondence to: Dr. Patricia K. Morley-Forster, Room F 208, St Joseph’s Health Care, London, Ontario N6A 4L6, Canada. Phone 519-646-6000, ext 65065; Fax 519-646-6376; E-mail: pat.morley-forster{at}sjhc.london.on.ca

Purpose: Both opioid and non-opioid medications are being utilized increasingly in the treatment of chronic non-cancer pain, and the number of surgical patients receiving large regular doses of opioids is ever-expanding. The perioperative pain control of these patients is often challenging, and is broadening the role of the anesthesiologist as ‘perioperative physician’. These patients need to be identified before surgery to plan optimal pain control postoperatively. The purpose of this review is to provide an update on the important considerations in managing the chronic non-cancer pain patient receiving high dose opioids and other adjunctive medications/analgesics.

Source: English language articles published between June 1980 and May 2006 were identified by a computerized Medline search using keywords chronic pain, opioid dependent and perioperative. This same search strategy was repeated and updated using both Medline and Embase. All relevant publications were retrieved and their bibliographies were scanned for additional sources.

Principal findings: Although an increasingly common problem for the acute pain service, there is very little published on this topic. Key points include the concept of opioid equivalency, tolerance, the role of adjunctive medications, and the need for good communication between the surgical team, the acute pain service and the patient who is often anxious about the upcoming procedure due to previous unpleasant experiences with poor pain control in hospital.

Conclusion: Clinical care of the opioid-dependent patient in the perioperative period can be a daunting task. Education to all staff involved in this area needs to be enhanced to improve outcome and patient satisfaction.