Perioperative pain management in patients with chronic pain who are treated with long-term opioids can be difficult. Stanlies D’Souza, MD, the chief of the neuroanesthesia division at Baystate Medical Center/University of Massachusetts Medical School, in Springfield, describes one such challenging case of using multimodal analgesia preoperatively for a patient recovering from opioid dependency during the 2018 annual meeting of the American Society of Anesthesiologists, in San Francisco.

The patient, who was recovering from heroin addiction with a history of chronic pain, came to Dr. D’Souza’s hospital for a sternal hardware removal, open reduction, and internal fixation and cadaveric bone graft for a nonunion of prior sternotomy. He and his pain physician were concerned about discontinuing buprenorphine/naloxone, a drug used to treat opioid dependence. The approach was to continue buprenorphine/naloxone in the perioperative period and utilize multimodal analgesia. The multimodal technique involves a combination of medications to address various pain receptors and pathways. Specifically, the patient received IV acetaminophen, ketamine, dexmedetomidine, high-dose fentanyl and IV lidocaine. After an uneventful perioperative course, the patient was comfortable in the postoperative period, and multimodal analgesia proved to be an effective pain management strategy.

Dr. D’Souza stated that one issue involved with the perioperative uses of buprenorphine/naloxone is that no guidelines currently exist. He explained three ways of managing a patient with chronic pain:

• Discontinue buprenorphine/naloxone three to five days before and add any additional opioids. Once the perioperative period has ended with opioids, continue buprenorphine/naloxone.
• Continue buprenorphine/naloxone and use high-dose opioids.
• Continue buprenorphine/naloxone and use multimodal techniques.

Dr. D’Souza and his team used the third approach to treat the patient recovering from a heroin addiction and explained that he traditionally uses this approach for all patients with chronic pain. Whenever possible, he uses nonsteroidal anti-inflammatory drugs and other multimodal techniques.

He expressed his concern about the opioid crisis in the community: “The U.S. is using 80% of the opioids in the world; I am very much concerned about it.” In Dr. D’Souza’s hospital, there are no set guidelines; therefore, the surgical team and the patient created a successful approach together. However, he believes now is the right time for the American Pain Society to consider establishing national and international guidelines.

—Anna DeNelsky