Anaes · Perioperative medicine
Opioid-tolerant and chronic pain patient — perioperative care
Also known as Opioid tolerance perioperative · Chronic pain acute-on-chronic · PCA adjustments opioid tolerant · Multimodal analgesia chronic opioid
Exam-pass perioperative care of the opioid-tolerant chronic pain patient: baseline opioid continuation, multimodal and regional strategies, PCA adjustments, acute-on-chronic pain, buprenorphine/methadone principles, and safe discharge for ANZCA Final and equivalents.
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Red flags
- Stopping baseline opioids peri-operatively causes withdrawal plus uncontrolled pain.
- Standard opioid-naive PCA settings under-dose tolerant patients and generate crisis calls.
- Background opioid infusions on unmonitored wards risk fatal respiratory depression.
- Moralising or withholding analgesia is not anaesthetic skill.
- New long-term high-dose opioids at discharge without plan create long-term harm.
Meet the patient
A 52-year-old taking oxycodone 40 mg twice daily plus amitriptyline for chronic back pain needs an L4 to L5 decompression. She is terrified of withdrawal, her pain score is already 7 out of 10 before surgery, and the night registrar has written a standard opioid-naive morphine PCA.[1]
The problem is not her pain threshold — it is that her receptors are downregulated. Stopping her baseline opioid guarantees withdrawal plus uncontrolled surgical pain, and a naive PCA will under-dose her catastrophically. The plan must be built before she reaches the holding bay.[1]
References6ShowHide
- [1]Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council J Pain, 2016.PMID 26827847
- [2]Neal JM, Barrington MJ, Fettiplace MR, et al. The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017 Reg Anesth Pain Med, 2018.PMID 29356773
- [3]Forero M, Adhikary SD, Lopez H, Tsui C, Chin KJ. The Erector Spinae Plane Block: A Novel Analgesic Technique in Thoracic Neuropathic Pain Reg Anesth Pain Med, 2016.PMID 27501016
- [4]Harrison TK, Kornfeld H, Aggarwal AK Perioperative Considerations for Medications for Opioid Use Disorder: Buprenorphine, Methadone, or Naltrexone Anesthesiol Clin, 2025.PMID 41233100
- [5]Ward EN, Quaye AN, Wilens TE Opioid Use Disorders: Perioperative Management of a Special Population Anesth Analg, 2018.PMID 29847389
- [6]Schwenk ES, Viscusi ER, Buvanendran A, et al. Consensus Guidelines on the Use of Intravenous Ketamine Infusions for Acute Pain Management From the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists Reg Anesth Pain Med, 2018.PMID 29870457