Acute and perioperative pain, including opioid-tolerant patients

Treat acute pain with multimodal analgesia and regional techniques, keep opioid exposure as low as works, and in opioid-tolerant patients continue the baseline opioid and add acute analgesia on top.

1. Multimodal analgesia is the default. The multisociety postoperative guideline strongly recommends combining analgesics and techniques with nonpharmacologic care, on high-quality evidence; combining acetaminophen, an NSAID, local anesthetic and regional techniques improves control while lowering opioid dose and opioid-related harms such as sedation and nausea ¹².
2. PCA without a routine basal infusion. In opioid-naive adults, adding a continuous background infusion to IV PCA is recommended against (strong, moderate quality); a basal infusion keeps delivering drug when the patient is asleep, bypassing the safety of demand dosing. Monitor sedation and respiratory status in anyone receiving systemic opioids ¹².
3. Opioid-tolerant patients need more, not less. Continue the usual opioid or an equivalent to prevent withdrawal, add short-term, sometimes much higher than average, opioid doses, and use nonopioid and adjuvant drugs. Plan discharge early to limit how long the extra opioid continues ³.
4. Ketamine is the evidence-based opioid-sparing adjunct. Subanesthetic ketamine should be considered for painful surgery (grade B) and may be considered in opioid-tolerant patients (grade B, low certainty); a trial in opioid-tolerant back surgery reduced opioid use for 6 weeks ⁴.
5. Rib fractures: protect breathing. EAST conditionally recommends epidural analgesia and multimodal analgesia for blunt thoracic trauma, though evidence quality is low; uncontrolled pain causes splinting, atelectasis and pneumonia, especially in older adults ⁵.
6. Postdural puncture headache. After failed conservative care, the epidural blood patch remains the most effective treatment; consensus guidelines do not support routine sphenopalatine ganglion block ⁶.

Active opioid use disorder is not a reason to withhold acute analgesia: meet the baseline requirement, treat the pain, and offer buprenorphine or methadone treatment ³⁷.

• Routine basal PCA infusion in opioid-naive adults: strong recommendation against ².
• Perioperative multimodal analgesia: strong recommendation, high-quality evidence ².
• Ketamine for opioid-dependent or opioid-tolerant surgical patients: may be considered, grade B, low certainty ⁴.
• The multisociety guideline limits its IV lidocaine recommendation to open and laparoscopic abdominal surgery ¹.
• EAST 2016 conditionally recommends epidural and multimodal analgesia for rib fractures ⁵.
• Dental extraction: NSAID alone or with acetaminophen is first-line; opioids are reserved for rare inadequate responses ⁸.
• CDC: in untreated opioid use disorder with pain, consider buprenorphine or methadone, which also help pain ⁷.

• Ordering opioid-naive doses for a patient on long-term opioids, or stopping the home opioid before surgery ³.
• Adding a sedating gabapentinoid to a rib-fracture patient already oversedated by opioids ⁵.
• Reaching for a sphenopalatine ganglion block as standard care for refractory PDPH instead of an epidural blood patch ⁶.
• Making analgesia conditional on a patient with opioid use disorder agreeing to addiction treatment ³.