narcotic pain medications during the postoperative period of
22, 23 Studies demonstrate that these protocols
lower overall use rates and duration of opioid analgesic use
Integral to the education of both young and practicing surgeons is a basic understanding of the neuroanatomy of pain.
Understanding the biochemical properties of tolerance, physical dependence, and addiction is paramount to responsible
opioid prescribing. Tolerance is defined as the biophysical
modulation of opioid receptors after chronic exposure. With
chronic opioid exposure, the receptors require an increased
amount of activation for the same result. As a consequence,
escalating amounts of narcotics are needed to achieve the same
level of pain relief.
25, 26 Physical dependence is the manifestation
of withdrawal symptoms due to cessation of the medication.
Physiologically, this will occur in all patients to a varying
degree. The most pronounced symptoms of withdrawal
include diaphoresis, agitation, tachycardia, vomiting, and
diarrhea. Addiction is characterized by behavioral changes,
such as seeking out the medication despite personal harm to
themselves or others.
Management of acute surgical pain poses several unique
challenges. Recognizing the overlay of acute and chronic
pain in the postoperative period can be difficult. Due to tolerance, postoperative pain control in patients with chronic
pain will require increased amounts of narcotics to provide
relief. Because opioid-tolerant patients experience more pain
postoperatively, especially in the first 24 to 48 hours, recommendations include preoperative planning that involves input
from the patient’s caretakers, and multimodal agents like nonsteroidals and acetaminophen.
When developing a pain management plan, it is important
to consider specific patient populations with respect to narcotic
use. Exercise caution when administering opioids in elderly
patients, for example, due to changing pharmacokinetics and
pharmacodynamics associated with both aging and polyphar-macy.
30 Patients with cardiac and pulmonary comorbidities are
susceptible to increased cardiac and respiratory depression.
Renal and liver disease can prolong clearance and metabolism,
leading to longer medication half-life and adverse events.
Relationship between nonmedical prescription-
opioid use and heroin use. N Engl J Med.
13. Wickramatilake S, Zur J, Mulvaney-Day N, von
Klimo MC, Selmi E, Har wood H. How states are
tackling the opioid crisis. Public Health Reports.
14. Dowell D, Haegerich TM, Chou R. CDC guideline
for prescribing opioids for chronic pain—United
States, 2016. JAMA. 2016;315( 15):1624-1645.
15. Kerensky T, Walley AY. Opioid overdose prevention
and naloxone rescue kits: What we know and what
we don’t know. Addict Sci Clin Pract. 2017; 12( 4): 1-7.
16. Davis CS, Ruiz S, Glynn P, Picariello G, Walley AY.
Expanded access to naloxone among firefighters,
police officers, and emergency medical technicians
in Massachusetts. Am J Public Health. 2014; 104( 8):e7-9.
17. Davis CS, Walley AY, Bridger CM. Lessons
learned from the expansion of naloxone access
in Massachusetts and North Carolina. J Law Med
Ethics. 2015; 43( 1 Suppl): 19-22.
18. Volkow ND, Frieden TR, Hyde PS, Cha SS.
Medication-assisted therapies—tackling the opioid-overdose epidemic. N Engl J Med. 2014;370( 22):2063-
19. Alderks CE. Trends in the use of methadone and
buprenorphine at substance abuse treatment
facilities: 2003 to 2011. The CBHSQ Report. Rockville,
MD. 2013. Available at: www.ncbi.nlm.ni
books/NBK384659/. Accessed June, 29 2017.
20. Ali MM, Dowd WN, Classen T, Mutter R, Novak
SP. Prescription drug monitoring programs,
nonmedical use of prescription drugs, and heroin
use: Evidence from the National Survey of Drug
Use and Health. Addict Behav. 2017;69: 65-77.
21. Patrick SW, Fry CE, Jones TF, Buntin MB.
Implementation of prescription drug monitoring
programs associated with reductions in opioid-related death rates. Health Aff. 2016; 35( 7):1324-1332.
22. Miller TE, Thacker JK, White WD, et al. Reduced
length of hospital stay in colorectal surgery after
implementation of an enhanced recovery protocol.
Anesth Analg. 2014;118( 5):1052-1061.
23. Sen H, Sizlan A, Yanarates O, et al. A comparison of
gabapentin and ketamine in acute and chronic pain
after hysterectomy. Anesth Analg. 2009; 109( 5):1645-
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