Acute pain management in opioid tolerant patients. Muhammad Laklouk

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1 Acute pain management in opioid tolerant patients Muhammad Laklouk

2 General principles An adequate review and assessment Provision of effective analgesia (including attenuation of tolerance and hyperalgesia) Prevention of withdrawal from opioids Involvement of multidisciplinary / specialist teams Organisation of appropriate management on discharge

3 Definitions Dependence syndrome (ICD- 10) A cluster of behavioral, cognitive, and physiological phenomena that develop after repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state. Active vs controlled dependence Pseudoaddicton: associated with undertreatment of pain, opioid seeking behaviours, disappears when pain is effectively treated.

4 Assessment and screening Non judgemental empathic attitude, gain patient s trust and establish good rapport. Ascertain and reconcile patient s medications, plan discharge and liaise with primary care regarding de- escalating opioids. Verify use and dosage of OST (Methadone, Buprenorphine) Identify psychiatric comorbidities (severe anxiety / depression) Urine screening?

5 Pain management

6 Withdrawal prevention

7 Opioid induced hyperalgesia Definition of OIH increased pain sensitivity OIH vs tolerance Management: Recognition Multimodal analgesia paracetamol, NSAIDs, Regional techniques Ketamine Other adjuvants: Clonidine, Dexmedetomidine, Gabapentinoids

8

9 Example 1 Patient taking 200mg of slow release oral morphine in divided doses for a number of years has a fixation of a fractured tibia. How do you manage post- operative pain?

10 Multimodal analgesia If able to drink allow to continue usual SR oral morphine, 1/6 of the daily dose can be given as oral morphine solution for breakthrough pain (30mg) If unable to drink: 200mg/day oral morphine is equivalent to about 70mg/day iv morphine (3mg per hour), start a PCA with a background infusion rate of a little less (about 50%) than calculated (2mg/hr) Might be reasonable to give a higher bolus for instant relief (2mg rather than 1mg)

11 Example 2. Patient undergoes total abdominal hysterectomy, has been using fentanyl patch 100 mcg/hr for back pain for last 2 years. How do you manage post- operative pain?

12 Multimodal analgesia Should have been advised to leave patch on before surgery Continue patch, might be reasonable to commence a PCA morphine with a bolus starting at 2-3mg. (100mcg Fentanyl patch = 400mg/day oral morphine = 130mg i.v morphine) Remember fentanyl absorption can change with pyrexia, sweating and hypovolaemia.

13 Example 3. Patient needing emergency laparotomy and expected to be nil by mouth. Normally takes 100mg/day oral Methadone for opioid dependence (ex IVDU).

14 Opioid rotation needed: convert Methadone to oral morphine dose (1:2 or 1:3) to prevent withdrawal. In this example it will be 300mg oral morphine (= 100mg i.v morphine) A 50% reduction in equianalgesic dose is recommended due to incomplete cross tolerance between opioids. (50mg of i.v morphine / 24 hours is needed to prevent withdrawal) With a morphine PCA: either increase the bolus to 1.5 to 2mg, or use a standard bolus (1mg) with a background of 2mg/hr

15 Example 4. Post BKA amputation patient requiring i.v morphine on a daily basis for 2 weeks. How do we further manage his opioids?

16 Convert to oral medication: calculate i.v morphine consumption in last 24 hours (for example 60mg). 50% of the oral equivalent dose is given in sustained release form and 1/6 of the oral equivalent prescribed as immediate release form every 4 hours mg oral morphine, 50% of this dose is 60-90mg (give 30-45mg MST B.D) + 1/6 of this dose PRN 4 hourly (20-30mg oral morphine solution)

17 Example 5. Example 5. A fibromyalgia patient who is normally on Buprenorphine patches undergoes a laparotomy. How do we manage post- operative pain?

18 Multimodal analgesia Lack of consensus in this area, not enough experience / studies available Continue the use of Buprenorphine (patch or sublingual), patients may benefit if SL form split into 2-3 daily doses. Use higher doses of immediate release opioids according to clinical situation, might need HDU environment if using excessive doses of full agonists.

19 Example 6. Post AKA patient complaining of persistently high pain scores despite high dose morphine via PCA and regular paracetamol. Constant burning sensation, unable to sleep or mobilise. How do you proceed with further management?

20 Combination of pharmacological, physical and behavioural therapy How to diagnose? (e.g ineffective pain relief despite increasing opioids, onset of sedation but still having high pain scores) Is there a role for opioids and tramadol? (yes opioids work but less effective than for nociceptive pain) First line agents: Gabapentinoids, TCAs (Amitryptiline), SNRIs (Duloxetine), NMDA antagonists (ketamine) Other adjuvants: Lidocaine, clonidine. Institution of preventive analgesia prior to amputation (epidurals, nerve blocks, ketamine) Use of regional blockade (ineffective, can give short term relief which is beneficial, catheter techniques for localised pain) Salmon Calcitonin (for phantom pain) Think about long term: involve MDT, discharge plan, communicate with primary care

21 Example 7. Prostate cancer patient with bone metastases complaining of increasing pain. Opioids escalating but pain getting worse. Also getting allodynia and pain in different locations. Why is this happening?

22 Differential diagnosis: opioid tolerance, disease progression, opioid withdrawal, opioid addiction, or pseudo addiction. Important to differentiate OIH from others. Can occur even with short term use of opioids Increase opioid dose: if pain better suggests tolerance, if worse OIH likely Gradually reduce opioid, use opioid sparing agents Opioid rotation (fentanyl, buprenorphine, methadone) NMDA antagonism Peripheral / regional nerve blockade Involve MDT, psychological / cognitive therapy

23 Thank you Questions?

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