Postoperative pain is extremely difficult to control in patients with opioid use disorder
The "pain system" of individuals who have been taking opioids daily before surgery is less responsive to opioids administered after surgery. The reduction in opioid effect with repeated drug exposure is called "opioid tolerance". Therefore, these patients require higher doses to achieve pain relief.
Chronic use of opioids leads to an increased sensitivity of pain pathways. As a result, stimuli that are typically little painful, such as a small and superficial incision, can produce strong pain, and major surgery can cause excruciating pain. This form of enhanced pain sensitivity is called opioid-induced hyperalgesia: paradoxically, the chronic use of a medication that should help reduce the pain makes the pain more difficult to control.
Patients with opioid use disorder have very frequently anxiety, depression, or other mental health problems that enhance pain.
Patients frequently request very high opioid doses after surgery
They have very good reasons to do so, for the reasons mentioned above. However, judgment and decision making are impaired in patients with opioid use disorder. Anxiety may also drive requests for dose escalation. Therefore, it is extremely difficult for clinicians to determine if patient's request for high opioid doses is caused by high activity of neural pathways involved in pain perception, or other factors such as addictive behavior and anxiety. Depending on the cause, escalating opioid doses may either help or harm patients.
Prescribing high opioid doses has a price
One may argue that patients with opioid use disorder are little sensitive to opioids and can therefore tolerate very high doses. This is only partly true. It is very common to observe excruciating pain and high level of sedation in these patients, which exposes them to high risk of respiratory depression and death.
The higher the opioid dose, the more difficult it will be to taper the dose down to a level that allows a safe hospital discharge. The higher the opioid use during the hospitalization, the higher the chance of higher long-term opioid use.
Patients do need high opioid doses, so how should we behave?
Doses higher that usual are inevitable in patients with opioid use disorder, also after minor surgery that would not necessarily require opioids for pain management. The use of patient-controlled analgesia for major surgery, whereby patients self-administer intravenous opioids using an electronic pump, is standard of care also in patients with opioid use disorder. Clinicians may feel uncomfortable with prescribing intravenous opioids in this condition, but for major surgery this is unavoidable. Denying patients this care raises ethical questions and is scientifically unjustified.
While high doses are inevitable, the crucial question is how far we can increase. There is no clear-cut answer. The decision is based on a number of considerations, such as type of surgery, previous opioid use, level of sedation, and predicted length of hospital stay, among others.
How to deal with patient's request that cannot be satisfied?
We frequently face the challenging combination of very high levels of pain, patient's request to increase the doses of opioids, and signs of sedation or somnolence. Even in this situation, patients are apparently not concerned by the associated risks and will still request dose increases. This is not surprising. By definition, patients with opioid use disorder take opioids even when they know that they are causing or will cause problems.
Clinicians have to deal with a mix of thoughts that include the desire to make patients comfortable, and the frustration of being unable to meet this goal. Not uncommonly, the communication is complicated by confrontations or patient's aggressive behavior.
Tips for clinicians
Consider that patient's request of opioid escalation is straightforward: opioid use disorder is a disease that impairs judgment and insight. Therefore, do not judge patients.
Tell yourself that providing responsible care is your priority, and this may be incompatible with patient's expectation.
Consider telling patients that the difficult situation is not their fault, but the result of our inability as scientific community to find solutions. This may help them understand that you are not stigmatizing their condition or undertreating their pain due to their "addiction".
Stress the necessity to work together to find a reasonable solution.
Each time you and patient agree on a plan, express your appreciation for their willingness to work with you.
After each visit, examine and discuss the interaction with the patient with your trainees and staff.