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John Wolfe, MD Assistant Professor of Clinical Anesthesiology Indiana University Hospital Chronic Pain Patients Post-op pain can be difficult to manage in patients with chronic pain, especially if the patient has been taking opiates at home. Chronic pain is often accompanied by anxiety, depression, and other psychiatric conditions which complicate care. Chronic Pain Patients Managing pain control expectations preop is helpful. Make sure that your patient understands that if their pain score is 8/10 prior to surgery, it won’t be 1/10 after surgery. Help patients understand how side effects may limit the doses of opiates that we give them. Preoperative Discussion Discussion of the following with the patient: Precise opioid use (drug, dose, schedule). Anticipation of increased postoperative pain. Patient’s fears and expectations related to pain management. Effective management strategies after previous procedures. Postoperative pain management plan. Chronic Pain Patients Remember that a chronic pain patient’s vital signs are not a good indicator of their pain level. The only way to determine how much pain the patient is having is to ask… Opioid Tolerance Defined as increasing doses of opioids to produce the same pharmacological effect. No tolerance to miosis and constipation effects. Tolerance depends on type of medication, route of administration etc. Tolerance to effects occurs at different rates. Tolerance to analgesic effect does not imply same level of tolerance to sedation or respiratory depression. Dependence implies development of withdrawal symptoms on abrupt discontinuation. Opiate-Tolerant Patients Expect opiate tolerance in anyone taking: Hydrocodone or oxycodone > 30 mg daily Any amount of oral morphine or Dilaudid Methadone A fentanyl patch Any recreational opiates Patients often minimize their opiate intake. You may have to go over the patient’s home meds several times to get an accurate accounting. Opiate-Tolerant PCA Dosing Approach to dosing: Convert the patient’s home opiates to an equivalent dose of IV morphine or Dilaudid. Dose converters are available online. Set the PCA so that the patient can increase total opiate intake by 25-50% over the home dose. Be prepared to increase the PCA dose. Use non-opioid analgesics whenever possible (ketorolac, APAP, ibuprofen). PCA Basal Rates Consider a PCA basal rate in any patient who is NPO and who was taking sustained-release opioids at home. Convert the sustained-release daily dose to an IV hourly equivalent, and set the initial basal rate for 50-75% of that hourly dose. Never run a basal rate on a patient who has sustained-release opioids or a fentanyl patch. Opiate-Tolerant Patients Remember that opiate-tolerant patients are at higher risk for respiratory depression than opiate-naïve patients. Tolerance to analgesia develops more rapidly than tolerance to respiratory depression. Patients may have enough opiate on board to be apneic, but still complain of 10/10 pain every time you wake them up. Pseudoaddiction Resembles addiction superficially. Behavior is a response to uncontrolled pain. Once pain is treated by appropriate measures including increased opioids, the behavior resolves. Patients are often labelled as “drug seeking”. Opioid-Induced Hyperalgesia Chronic exposure to opioids can increase pain sensitivity in some patients. “Rewiring” occurs at the level of the spinal cord and brainstem. Pain stimuli that should be minor are perceived as severe (hyperalgesia). Non-painful stimuli can be perceived as pain (allodynia). Unsurprisingly, increasing the opioid dose is not terribly effective. Predictors of chronic persistent postoperative pain Preoperative factors Presence of preoperative pain. Repeat surgery. Psychological vulnerability (eg, neuroticism). Work-related injury. Surgical factors Type of surgical procedure (breast, thoracotomy, inguinal hernia). Surgical approach with risk of nerve damage. Postoperative factors Intensity of early postoperative pain. Postoperative radiation therapy or chemotherapy. Neuropathic Pain Qualities of neuropathic pain: Pain may be described as “shocking” or “electrical”. Pain follows a nerve distribution rather than correlating with the surgical incisions. Pain is out of proportion to the incisions. Try starting gabapentin 600 mg bid or tid. Sedation is the main side effect to watch for. Pain Consults At IU Hospital, there are 3 pain services: Anesthesia Acute Pain: Short-duration invasive pain procedures, like epidurals and intrathecals. Palliative Care (Dr. Aref): Management of inpatient opioid tolerance, complicated pain regimens, and general symptom management. Chronic Pain Clinic (Dr. Wellington and Dorwart): Management of intrathecal pumps, spinal cord stimulators, and outpatient analgesics. Pain Consults If your patient would benefit from a block, or has side effects from a block, call APS (312-2787). If you need to know what to do with your patient’s intrathecal morphine pump, call the patient’s chronic pain physician. If you need help with figuring out an oral pain regimen for a patient to go home on, call Dr. Aref. Feel free to email me with questions or for a copy of this PowerPoint: [email protected]