High-quality preoperative pain control is critical to providing optimal perioperative pain management, but there is a lack of guidelines for preoperative opioid and nonopioid pain medication dosing for surgical patients.

This dearth of evidence has been tied to suboptimal preoperative pain control. As a result, the Society for Perioperative Assessment and Quality Improvement (SPAQI) identified multiple domains in which a consensus statement might improve patient care. This consensus statement was published in the Mayo Clinic Proceedings.

Using a modified Delphi method, the SPAQI solicited input from a group of experts in anesthesiology, perioperative medicine, and pain medicine about preoperative pain management through medication. The medications in question were divided into 6 groups: opioid agonists, opioid antagonists, opioid agonists/antagonists, acetaminophen, muscle relaxants, and triptans/headache pain medications. A literature search was then conducted to identify relevant research.


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A summary of the consensus recommendations follows.

Opioid Agonists

Patients should take most opioid agonists preoperatively, including the day of surgery. Special considerations should be made for prodrugs (codeine and tramadol), opioids with serotonin reuptake inhibitory activity (levorphanol, meperidine, fentanyl, methadone, tapentadol, and tramadol), and transdermal fentanyl.

Preoperative meperidine dosing should be considered and adjusted based on individual patient and clinical circumstances. Patients should be evaluated to determine whether meperidine is the best medication for long-term therapy based on the drug’s poor efficacy, toxicity, and drug-drug interactions.

Patients who are on long-term opioid therapy will likely require either higher than usual doses to achieve pain control or adjunctive nonopioid analgesia perioperatively. Patients who can reduce the dosing of preoperative opioids can or who can tolerate a modified regimen with the addition of nonopioids should do this. Weaning off of opioids should be done in an individualized way to ensure optimal pain control.

Opioid Antagonists

lvimopan, methylnatrexone, naldemedine, and naloxegol can be taken preoperatively but should be held on the day of the operation. Naloxone can be taken preoperatively if it is administered orally or in combination with another medication. When administered through another route — typically for respiratory depression in unstable patients — the dose and timing should be communicated with the perioperative team.

Both oral and extended-release naltrexone should be held for elective surgical procedures when perioperative opioid use is expected. Oral naltrexone should be held for 2 to 3 days and extended-release naltrexone should be held for 24 to 30 days after the last injection.

Opioid Agonist-Antagonists

Buprenorphine treatment should be adjusted based on individual patient and clinical circumstances. For most patients, continuation of buprenorphine through the day of the operation is recommended, particularly with the use of full mu agonists if pain control is inadequate.

Butorphanol, nalbuphine, and pentazocine should be taken preoperatively, including on the day of the surgical procedure.

Headache and Pain Medications

Ergotamine should be held for at least 2 days prior to the operation. Butalbital should be held the day of the operation; patients who use long-term of intermittent butalbital should be weaned slowly off the medication over 2 weeks prior to the operation. In situations where preoperative weaning is not possible, butalbital should be taken preoperatively to avoid perioperative withdrawal.

Triptans can be taken preoperatively but should be held the day of the operation. Erenumab-aaoe, fremanezumab, and galcanezumab should be taken throughout the preoperative period; surgeries can be scheduled at any time during the cycle, including on the day of the injection.

Muscle Relaxants

Baclofen and tizanidine can be taken preoperatively, including on the day of the operation. Carisoprodol should be held the day of the operation, and when time permits, should be tapered off or switched to a different agent prior to any surgical procedures. Cyclobenzaprine, metaxalone, methocarbamol, and ophrenadrine should be held on the day of any surgical procedures.

Acetaminophen

Acetaminophen is a common perioperative analgesic that is used either alone or as a part of a multimodal analgesia treatment plan. Acetaminophen can be taken preoperatively, including on the day of the surgical procedure.

“Optimal perioperative pain control is a key component of good surgical care,” the researchers concluded. “Hopefully, this clinical consensus guideline can improve patient care by allowing perioperative physicians to make optimal choices for preoperative pain control for their patients.”

Disclosure: Researchers received funding support from Merck, Medtronic/Coviden, AcelRx, Takeda, Heron, and Acacia. Please see the original reference for a full list of authors’ disclosures.

Reference

O’Rourke MJ, Keshock MC, Boxhorn CE, Correll DJ, O’Glasser AY, Gazelka HM, et al. Preoperative management of opioid and nonopioid analgesics: Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement. Mayo Clin Proc. Published online February 19, 2021. doi:10.1016/j.mayocp.2020.06.045