Codeine, Dihydrocodeine, Dipipanone, Fentanyl [transdermal], Hydromorphone, Meptazinol, Morphine, Oxycodone, Pentazocine, Pethidine, Tapentadol, Tramadol
[For methadone and buprenorphine see individual monographs] |
Issues for Surgery |
Loss of analgesic effect if omitted. For codeine use in high output stoma – loss of control of gastrointestinal stoma output if omitted. Risk of withdrawal if long-term treatment is abruptly discontinued (see Further Information). Risk of opioid-induced ventilatory impairment (OIVI) if continued (see Further Information). Risk of persistent post-operative opioid use (PPOU) in both opioid sensitive and opioid naïve patients (see Further Information). Risk of opioid-induced hyperalgesia (OIH) and tolerance, secondary to chronic opioid use, if continued (see Further Information). Risk of worse perioperative outcomes if continued (see Further Information). Risk of serotonin syndrome if fentanyl, pentazocine, pethidine, tapentadol or tramadol are continued (see Interaction(s) with Common Anaesthetic Agents and Interaction(s) with other Common Medicines used in the Perioperative Period). |
Advice in the Perioperative period |
Elective Surgery If this is not possible, continue1 (including non-aspirin containing combination products – see below). Escalation of doses prior to surgery should be avoided. Confirm brand, dose and frequency with patient and consult British National Formulary to confirm appropriateness of dosing schedule (see Further Information). Patients should be screened for chronic pain and opioid use pre-operatively and the Oral Morphine Equivalent per 24 hours (OME) of prescribed opioids should be recorded. Opioid tolerance is likely at 60mg OME for ≥ 7 days2. For opioid equivalence information please refer to the Faculty of Pain Medicine information ‘Dose equivalents and changing opioids’ available at https://fpm.ac.uk/opioids-aware-structured-approach-opioid-prescribing/dose-equivalents-and-changing-opioids. Specialist pain team input should be obtained for patients with complex pain management2 and patients with uncontrolled pain despite high opioid doses as this may indicate opioid-induced hyperalgesia or opioid tolerance (see Further Information).
Except:
Consideration should be given to prescribing the components of combination products as separate medicines perioperatively, to facilitate review of their appropriateness and encourage deprescribing. See also Post-operative Advice below.
Absorption from a transdermal patch can be increased by heat, e.g. perioperative warming devices, whereas absorption may be reduced if poor perfusion or reduced temperature3.
Patients who cannot take oral opioids, should be offered a choice of patient-controlled analgesia (PCA) or a continuous epidural to relieve pain after surgery, where clinically indicated4. Combination analgesics such as tablets containing paracetamol with an opioid (e.g. co-codamol) should be avoided post-operatively as the fixed doses do not allow for titration to patient need, or the flexibility required for weaning5.
Opioid Naïve Patients
Review opioid if patient develops a paralytic ileus9.
Opioid Naïve Patients
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Interaction(s) with Common Anaesthetic Agents |
*meptazinol and pentazocine have mixed agonist and antagonist properties; adequate analgesia may be difficult to achieve when administering a full opioid agonist. ** benzodiazepines (and benzodiazepine-like drugs) and opioid medicines (opioids) can both cause respiratory depression; when used together, additive effects on the central nervous system increase the risks of sedation, respiratory depression, coma, and death11 (see Further Information).
Patients should be monitored closely, and the possibility of serotonin toxicity considered if patients experience altered mental state, autonomic dysfunction or neuromuscular adverse effects with concomitant treatment. *meptazinol and pentazocine have mixed agonist and antagonist properties; adequate analgesia may be difficult to achieve when administering a full opioid agonist. Bradycardia
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Interaction(s) with other Common Medicines used in the Perioperative Period |
Other medications
Monitor patients for symptoms of serotonin syndrome such as fever, tremors, diarrhoea, and agitation. Concurrent treatment should be stopped if serotonin syndrome occurs9. CNS Depression (also see under Interaction(s) with Common Anaesthetic Agents and Opioid-Induced Ventilatory Impairment in Further Information)
Gabapentin and Pregabalin Consider adjusting the dose of gabapentin / pregabalin for patients who are prescribed opioid-containing medication in the post-operative period12, 13 – see also Gabapentin monograph and Pregabalin monograph Macrolide Antibiotics |
Further Information |
Before prescribing opioids, the following should be discussed with patients2, 5, 11: -
There should be appropriate pre-operative education for patients providing realistic expectations regarding their pain relief post-operatively. Information should be provided about multimodal analgesia, including non-pharmacological techniques and non-opioid analgesia2, 5. Patients should be provided with written information to advise them and their relatives / carers on the risks of dependence and addiction. A leaflet is available from https://www.britishpainsociety.org/static/uploads/resources/files/pain_management_print-ready_atwork_2.pdf) MHRA / CHM Advice – Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression (March 2020)9 Safe prescribing MHRA / CHM Advice – Dihydrocodeine with paracetamol (Co-Dydramol): Prescribe and dispense by strength to minimise risk of medication error (January 2018)9 Withdrawal Long-Acting Opioids Perioperative Outcomes Patients with a history of chronic opioid use who successfully decreased their use of opioids by at least 50% before arthroplasty surgery had substantially improved clinical outcomes which were comparable to patients not taking opioids15. Opioid Tolerance and Opioid-induced Hyperalgesia (OIH) Opioid-Induced Ventilatory Impairment (OIVI) Risk factors for OIVI include obesity, sleep-disordered breathing, chronic obstructive pulmonary disease, renal disease, cardiac disease, neurological disorders, patients with ASA status of 3 or 4 and patients aged >65 years. Risk is further increased by external factors including concomitant administration of other medications with CNS depressant effects (see Interaction(s) with Common Anaesthetic Agents and Interaction(s) with Other Common Medicines used in the Perioperative Period), inadequate monitoring, continuous infusions of opioids and administration of opioids by multiple routes. However, in many cases no identifiable comorbidities are present6. OIVI continues to cause patient harm in the acute pain setting, including death and hypoxic brain damage but the majority of events are considered preventable with better assessment and monitoring of all patients, not just those with risk factors6. Persistent Post-operative Opioid Use (PPOU) PPOU can occur with any opioid, not just ‘strong opioids’; indeed, tramadol use has been associated with a higher risk of PPOU than other short-acting opioids8 |
References |
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