HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Cramer et al

needs if they persist. If chronic pain persists after treatment of the disease, patients should be referred for multidisciplin- ary evaluation, as chronic opioid use after treatment for head and neck cancer is associated with decreased survival. 55 Patients with Chronic Pain Acute and chronic pain are distinct entities. Acute pain is a physiologic response to tissue damage, producing a noxious neurologic response. Chronic pain lasts 3 months or longer, and the extent of pain does not correlate with the extent of injury or noxious stimuli. 40 Chronic pain often starts as acute pain. Chronic pain is characterized by an abnormal state and function of nociceptive neurons that become hyperactive. 57 The development of chronic pain is associ- ated with duration of opioid use, scheduled opioid use, and the type of opioid used. 58 Vigilance about the normal response to acute pain to identify early stages of opioid dependence and chronic pain enables early referral to a chronic pain specialist. Operating on patients with preoperative chronic pain syn- drome who are opioid tolerant prior to surgery is a particu- lar challenge. In the perioperative care of these patients, surgeons should be comfortable involving a multidisciplin- ary team of pain specialists and pharmacists. Patients with chronic pain frequently have coexistent depression that can complicate pain control. 59 Preoperative referral for treat- ment of depression prior to elective surgery may improve postoperative pain control. Patients who are opioid tolerant prior to surgery will have considerably greater opioid requirements postoperatively secondary to opioid tolerance and hyperalgesia. 60 However, patients receiving chronic opioids do not develop tolerance to opioid-induced respira- tory depression. Thus, they are at increased risk of respira- tory depression. 61 Discussing the pain plan preoperatively helps to set expectations, and multimodal nonopioid agents preoperatively can lessen the need for increased opioids postoperatively. 23 The CDC has published guidelines on control of chronic pain that may be helpful to otolaryngolo- gists caring for patients with chronic pain but are beyond the scope of this review. 40 Nonopioid Strategies for Treating Acute Postoperative Pain In many patients, the risks of opioids can be avoided alto- gether or minimized with use of multimodality nonopioid anesthesia in the perioperative period. A concept that is essential to understand when considering the multimodal nonopioid analgesia discussed below is preventive analge- sia. The concept of preventive analgesia is that agents admi- nistered prior to a painful stimulus can modify processing of noxious stimuli by the peripheral and central nervous system, decreasing central sensitization and hyperalgesia. 62 Preventive analgesia requires multiple agents to block noci- ceptor activation, inhibiting activation or transmission of neurotransmitters. Meta-analysis of preventive analgesia

Table 2. Important Patient Information When Prescribed an Opioid after Surgery. a

When Prescribing Opioids for Pain, Patients Should Be Advised of:

Risks of opioids include Physical dependence, addiction, and overdose

especially susceptible to the sedating side effects of opioids, increasing the risk of falls, fractures, and death from any cause. 50,51 Thus, elderly patients and those with sleep apnea or cardiopulmonary disease should start with low-dose opiate medications and require vigilant titration to avoid adverse events. 24 Pediatric patients similarly deserve special attention and require developmentally appropriate pain assessment and dose adjustments based on age and weight. 24 Furthermore, children are at risk for accidental ingestion of opioids, and thus the safe storage and disposal of opioids with pediatric patients or patients with young children are paramount. 52 The incidence of pain in patients with cancer is exceed- ingly high 53 and requires a nuanced approach. It is esti- mated that 25% of cancer pain is related to treatment, including surgery and chemoradiation. Some patients with cancer-related pain will experience pain relief after removal of their cancer, and it is important to continue to assess the postoperative pain needs and decrease appropriately. 54 Chronic opioid use is common after head and neck cancer surgery, and after surgery for oral cavity cancer, chronic opioid use was identified in 41% of patients. 55 Pain related to radiation and chemotherapy is also extremely common. In patients with head and neck cancer actively receiving chemotherapy, 80% take opioids for pain. 56 While adequate control of pain related to cancer and treatment is vital, after treatment and disease control, it is necessary to assess pain Constipation, nausea, or vomiting Sleepiness, dizziness, or confusion Itching or sweating Respiratory depression Alternatives to opioids include acetaminophen, nonsteroidal anti- Do not take opioids with alcohol or central nervous system depressants such as sleeping pills, benzodiazepines, or muscle relaxants Do not drive, ride a bike, operate heavy machinery, or make important decisions while taking opioids Store all opioids in a safe place out of reach of children, friends, or visitors Safely dispose of any leftover medication by drop-off at approved collection sites or flushing pills down the toilet following recommendations from the Food and Drug Administration (www.fda.gov/Drugs/ResourcesForYou) inflammatory drugs, celecoxib, and gabapentin Take opioids as instructed on the prescription Do not give opioid medication to anyone else If strong pain continues, then see a doctor a Based on information from the Food and Drug Administration.

156