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Multiorganizational consensus to define guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder
  1. David M Dickerson1,2,
  2. Edward R Mariano3,4,
  3. Joseph W Szokol5,
  4. Michael Harned6,
  5. Randall M Clark7,
  6. Jeffrey T Mueller8,
  7. Ashley M Shilling9,
  8. Mercy A Udoji10,11,
  9. S Bobby Mukkamala12,
  10. Lisa Doan13,
  11. Karla E K Wyatt14,
  12. Jason M Schwalb15,
  13. Nabil M Elkassabany9,
  14. Jean D Eloy16,
  15. Stacy L Beck17,
  16. Lisa Wiechmann18,
  17. Franklin Chiao19,
  18. Steven G Halle20,
  19. Deepak G Krishnan21,22,
  20. John D Cramer23,
  21. Wael Ali Sakr Esa24,
  22. Iyabo O Muse25,26,
  23. Jaime Baratta27,
  24. Richard Rosenquist24,
  25. Padma Gulur28,
  26. Shalini Shah29,
  27. Lynn Kohan30,
  28. Jennifer Robles31,32,
  29. Eric S Schwenk33,
  30. Brian F S Allen34,
  31. Stephen Yang35,
  32. Josef G Hadeed36,
  33. Gary Schwartz37,38,
  34. Michael J Englesbe39,
  35. Michael Sprintz40,
  36. Kenneth L Urish41,
  37. Ashley Walton42,
  38. Lauren Keith7 and
  39. Asokumar Buvanendran43
  1. 1Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
  2. 2Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
  3. 3Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA
  4. 4Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
  5. 5Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
  6. 6Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
  7. 7American Society of Anesthesiologists, Park Ridge, Illinois, USA
  8. 8Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
  9. 9Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
  10. 10Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia, USA
  11. 11Atlanta VA Health Care System, Decatur, Georgia, USA
  12. 12American Medical Association, Chicago, Illinois, USA
  13. 13Department of Anesthesiology, PerioperativeCare and Pain Medicine, New York University School of Medicine, New York, New York, USA
  14. 14Department of Anesthesiology, Perioperativeand Pain Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
  15. 15Department of Neurosurgery, Henry Ford Medical Group, Detroit, Michigan, USA
  16. 16Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
  17. 17Department of Obstetrics, Gynecology, and Reproductive Sciences, Maternal Fetal Medicine, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
  18. 18Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
  19. 19Department of Anesthesiology, Westchester Medical Center, Valhalla, New York, USA
  20. 20Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  21. 21Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
  22. 22Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
  23. 23Department of Otolaryngology – Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA
  24. 24Department of Pain Management, Cleveland Clinic, Cleveland, Ohio, USA
  25. 25Department of Anesthesiology, Montefiore Medical Center, Bronx, New York, USA
  26. 26Department of Anesthesiology, Westchester Medical Center Health Network, Valhalla, New York, USA
  27. 27Department of Anesthesiology and Perioperative Medicine, Thomas Jefferson University Sidney Kimmel Medical College, Philadelphia, Pennsylvania, USA
  28. 28Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
  29. 29Department of Anesthesiology and Perioperative Care, University of California Irvine, Orange, California, USA
  30. 30Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
  31. 31Department of Urology Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  32. 32Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
  33. 33Department of Anesthesiology and Perioperative Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
  34. 34Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
  35. 35Department of Surgery, Division of Thoracic Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland, USA
  36. 36Hadeed Plastic Surgery, Beverly Hills, California, USA
  37. 37AABP Integrative Pain Care, Melville, New York, USA
  38. 38Maimonides Medical Center, Brooklyn, New York, USA
  39. 39Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
  40. 40Sprintz Center for Pain and Recovery, Shenandoah, Texas, USA
  41. 41Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
  42. 42American Society of Anesthesiologists, Washington, District of Columbia, USA
  43. 43Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
  1. Correspondence to Dr David M Dickerson, Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, IL 60201, USA; ddickerson{at}northshore.org

Abstract

Significant knowledge gaps exist in the perioperative pain management of patients with a history of chronic pain, substance use disorder, and/or opioid tolerance as highlighted in the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force 2019 report. The report emphasized the challenges of caring for these populations and the need for multidisciplinary care and a comprehensive approach. Such care requires stakeholder alignment across multiple specialties and care settings. With the intention of codifying this alignment into a reliable and efficient processes, a consortium of 15 professional healthcare societies was convened in a year-long modified Delphi consensus process and summit. This process produced seven guiding principles for the perioperative care of patients with chronic pain, substance use disorder, and/or preoperative opioid tolerance. These principles provide a framework and direction for future improvement in the optimization and care of ‘complex’ patients as they undergo surgical procedures.

  • acute pain
  • analgesics, opioid
  • pain management
  • opioid-related disorders
  • chronic pain

Data availability statement

Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. All data from the principle development process is available on request. The data have been shared in the text and supporting materials in its entirety.

https://doi.org/10.1136/rapm-2023-104435

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    Introduction

    In 2021, 14 professional societies completed a Delphi consensus process and Pain Summit yielding seven principles for acute perioperative pain management of the non-complex patient.1 The focus of these original principles was to provide guidance on the preparation, treatment, assessment, and ongoing engagement of patients receiving pain management for surgical procedures. Patients with chronic pain, substance use disorder (SUD) or preoperative opioid tolerance were excluded from the scope of the 2021 consensus process and summit. While the importance of preoperative identification of these patients was highlighted in the previous Summit and its consensus principles, the specific management of these more ‘complex’ patients was deferred. The 2021 Summit and consensus sought to address several unmet pain care delivery needs illustrated in multiple cross-disciplinary public health efforts such as the National Pain Strategy and the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force reports.2

    With similar intention but with a focus on perioperative pain management of the ‘complex’ patient, defined by the expert consortium as patients with chronic pain, preoperative opioid tolerance, or SUD, the previous participant organizations were reconvened for a second modified Delphi consensus process via electronic survey and Pain Summit. Given the focus of this summit, the American Society of Addiction Medicine (ASAM) was added to the consortium. The physician authorship represents a diverse spectrum of clinical backgrounds and practice settings. This publication provides a detailed description of the process steps and presents seven care principles developed through the 15 healthcare organization consensus process and 2022 national Pain Summit that finalized the consensus recommendations. While several specialty-specific clinical practice guidelines on opioid prescribing exist, this work product is unique in its focus on perioperative pain management for complex patients commonly excluded from prior consensus statements and guidelines as well as having the collaboration and endorsement of multiple medical societies.3–6

    The recommendations contained here do not define the standard of care and replace a physician’s clinical judgment or the needs of individual patient circumstances. In the imperfect setting of limited or evolving data, controversial topics, and bias inherent to expert opinion, specific application of these principles in lieu of alternative or personalized approaches may not necessarily result in improved outcomes.

    Methods

    In 2021, after completing the first Pain Summit; the American Society of Anesthesiologists (ASA) reconvened the steering committee (AB, DMD, MH, ERM, JR), and survey feedback was reviewed from Summit participants which detailed high satisfaction with the previous process and an interest and desire to participate in a future summit, especially one focused on ‘complex’ patients if engaged to do so (see online supplemental appendix A). After receiving support from the ASA Executive Committee (2021–2022), the methods from the prior Summit were followed in similar fashion.1 The steering committee agreed that the consensus process, Pain Summit planning, and the activities associated with developing any related work product would be free from industry influence or sponsorship. The methodology for the modified Delphi process for guiding principle development and the Pain Summit have been published previously1 and is detailed in online supplemental appendix B.

    Supplemental material

    Statistical analysis

    The sample of 13 organizational representatives (not including ASA and American Hospital Association (AHA)) was selected by convenience based on the number of participating organizations from the first Pain Summit with the addition of the ASAM. We defined consensus as a minimum threshold of 75% participant agreement which has been established as an acceptable threshold in previously published Delphi studies.7 Descriptive statistics were used to present data as appropriate.

    Results

    Fourteen organizations were contacted by ASA and invited to participate, and all 14 (100%) responded positively (box 1).

    Box 1

    Organizational participants in the 2022 Pain Summit and consensus process

    Organization

    1. American Hospital Association.

    2. American Medical Association.

    3. American College of Surgeons.

    4. American Academy of Orthopedic Surgeons.

    5. American Academy of Otolaryngology-Head and Neck Surgery.

    6. American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

    7. American College of Obstetricians and Gynecologists.

    8. American Association of Oral and Maxillofacial Surgeons.

    9. American Society of Breast Surgeons.

    10. American Society of Plastic Surgeons.

    11. American Society of Regional Anesthesia and Pain Medicine.

    12. American Society of Addiction Medicine.

    13. American Urological Association.

    14. Society of Thoracic Surgeons.

    15. American Society of Anesthesiologists.

    First round results

    Of the 13 Consortium representatives contacted in the first round (excluding ASA and AHA), all 13 (100%) completed the survey. Principles 1, 2, 3, 5, 6 and 8 achieved consensus with 100% agreement. Principle 4 achieved 69.2% agreement which was below the threshold for consensus in its original form. Similarly, principle 7 achieved 61% agreement. Online supplemental appendix C presents the wording of each of the original eight principles from first round to second round. Verbatim free text comments submitted by participants are shown in online supplemental appendix D.

    Second round results

    Since consensus was achieved for six of eight principles in the first round of voting, the focus of the second round was on the two principles that had not reached consensus. The statements were modified and reframed by the steering committee based on the first-round comments. As the round 1 survey suggested that preoperative tapering recommendations should be avoided and the preoperative opioid dose be maintained, principle four was revised for round 2 into two separate survey statements to clarify the consortium’s level of agreement on preoperative tapering, preoperative opioid dose continuation, and dosing of opioids in these populations.

    • Revised principle 4, part A: For patients on opioids preoperatively, clinicians should not routinely taper patients before surgery.

    Less than 50% of respondents in round 2 agreed with the part A of the revised principle 4 (30.8% disagreement, 23.1% agreement, and 46.2% neutral) resulting in exclusion.

    • Revised principle 4, part B: For patients on opioids preoperatively, clinicians should continue the baseline opioid dose in the perioperative period and supplement as needed for postoperative acute pain.

    Greater than 75% of respondents in round 2 agreed with part B (15.4% disagreement, 84.6% agreement) resulting in the decision to include part B as the new principle 4.

    Principle 6 from round 1 was revised in the round 2 survey to clarify the consortium’s level of agreement on educating at-risk patients and their caregivers about the respiratory depressant risk of opioids, potential interactions with other medications and alcohol, and indications for seeking medical attention. The revised language shown for principle 6 garnered 100% agreement in round 2.

    After engaging the consortium, the decision was made to divide principle #2 into two principles to focus discussion at the summit and in the supporting text on assessing patients with chronic pain or opioid tolerance separate from considerations for patients with SUD. The principles were reworded to specify which clinicians should be engaged in each situation. The list of nine principles accepted for live discussion at the Pain Summit is shown in box 2.

    Box 2

    Final accepted principles presented to ASA volunteers and Consortium in preparation for the Pain Summit

    1. In using preoperative screening tools, if clinicians identify a positive screen for substance use, a more detailed assessment tool should be used to risk stratify patients for additional support or referral for treatment when indicated.

    2. In conducting a preoperative evaluation, if a patient is identified to have chronic pain or opioid tolerance clinicians should coordinate with the patients’ other clinicians, including consultation with a pain specialist.

    3. In conducting a preoperative evaluation, if a patient is identified as having a substance use disorder, clinicians should coordinate with the patients’ other clinicians, including consultation with a behavioral health specialist. (Previously part of principle 2 in the first round survey)

    4. For patients taking opioids preoperatively, clinicians should coordinate with the patient’s prescribing clinician.

    5. For patients on opioids preoperatively, clinicians should continue the baseline opioid dose in the perioperative period and supplement as needed for postoperative acute pain.

    6. Clinicians should work with patients with opioid tolerance on an individualized tapering plan for postoperative pain medication, coordinating with the preoperatively prescribing physician, with the goal of return to the preoperative dose or lower as soon as possible.

    7. For patients prescribed opioids at discharge following surgery, clinicians should inform them and their caregivers about the risks, signs and management of opioid-induced respiratory depression; that they must avoid concurrent use of medicines with sedative effects and alcohol while taking opioids; and when to call for emergency assistance.

    8. For patients identified as at risk for increased perioperative pain control needs or opioid-related side effects, clinicians should consult a pain medicine or perioperative care specialist preoperatively.

    9. For patients identified as benefiting from additional consultation with a pain medicine or behavioral health specialist, clinicians should use telehealth options if in person consultation is not available.

    Third round results

    On February 26, 2022, 42 participants convened for the live virtual Pain Summit which included ASA volunteers, the steering committee members, ASA staff, and the Consortium representatives from the 15 professional organizations. The goal of the Pain Summit was explicitly stated: to finalize a set of foundational principles endorsed by all participating organizations on the acute perioperative pain management of complex adult surgical patients, specifically focused on patients with SUD, preoperative opioid tolerance, and/or chronic pain. Time was specifically allocated for the presentation of each principle, subsequent discussion, and voting if indicated as follows: principles 1, 2, 4, 5, 7, and 9 (5 min presentation; 10 min discussion); principle 3 (7 min presentation; 14 min discussion); principle 6 (8 min presentation; 10 min discussion), and principle 8 (6 min presentation 10 min for discussion and vote). Presentation and discussion times were allocated by the steering committee based on the volume and breadth of written comments generated during the two electronic survey rounds and review of the presentation materials submitted by each principle’s workgroup consisting of ASA volunteers and Consortium collaborators.

    Throughout the Pain Summit, participants shared their recommendations and suggested best practices for disseminating and implementing the new and previous-established principles. Like the prior Pain Summit, there was verbal agreement from Pain Summit attendees that the implementation of the Pain Summit’s principles again should be a physician-led initiative, but that they apply to any clinician engaged in providing perioperative care and pain management. Specifically, principle 8 was revised due to lack of clarity in the term ‘perioperative care specialist’; after voting, this term was better defined as an anesthesiologist or pain medicine specialist with unanimous support.

    Other themes that emerged from the discussion included: the importance of creating principles of value to direct current and future care improvement; ongoing patient access to pain and addiction medicine specialists; the role of unconscious bias and stigma; the challenges of care coordination; and a commitment to patient-centeredness and caregiver-centeredness through education and shared decision-making. Tapering of opioids was discussed separately after the other nine principles were presented. Routine preoperative tapering of patients’ long-term opioid therapy was eliminated in an earlier round based on a lack of strong supportive evidence and the Consortium’s agreement that preoperative opioid tapering should be a case-by-case decision between patients and their treating physicians. However, postoperative opioid tapering was included as principle 6 but with an emphasis on taking an individualized approach with clear goals. Gaps and barriers to successful uptake and implementation were discussed for each principle; the participants acknowledged that ongoing organizational collaboration and commitment with engagement of their membership would be critical to changing clinical practice based on these principles.

    Prior to dissemination, the list of nine principles presented at the Pain Summit was revised to seven as principles that were separated purely to discuss individual topics were consolidated based on parallel sentence structure and content overlap. Figure 1 illustrates the final guiding principles developed by the participating societies after the herein detailed three-round modified Delphi consensus and the second national Pain Summit.

    Figure 1
    Figure 1

    Guiding principles for perioperative pain management in patients with chronic pain, preoperative opioid tolerance, or substance use disorder.

    Discussion

    Following a three-round Delphi consensus process culminating in the second national Pain Summit, 15 professional medical societies developed and endorsed 7 key principles for acute perioperative pain management in the ‘complex’ surgical patient, defined as having a history of chronic pain, preoperative opioid tolerance, or SUD. This subpopulation is typically excluded from specialty society guidelines on pain management and opioid stewardship. Patients may have one or more or a combination of these conditions. These principles complement the previously established Pain Summit principles for the non-complex surgical patient and provide guidance for the development of future clinical practice recommendations, patient care pathways, and healthcare laws and regulations.

    Principle 1: In utilizing preoperative screening tools, if clinicians identify a positive screen for substance use, a more detailed assessment tool should be utilized to risk stratify patients for additional support or referral for treatment when indicated.

    SUD, as defined by the Diagnostic and Statistical Manual of Mental Disorders, incorporates 11 different criteria in the diagnosis.8 Although not routinely used in the perioperative period, two of the most used validated screening tools for SUD are the opioid risk tool (ORT) for OUD and the Screening, Brief Intervention, and Referral to Treatment (SBIRT) although many other validated screening tools are available.9 10 The validated tobacco, alcohol, prescription medication, and other substances use screener (TAPS1) and the more detailed TAPS2 for instances where a positive TAPS1 screen is obtained enable effective identification of probable SUD.11 12 The ability to refer a patient with potential SUD to an addiction specialist for a comprehensive evaluation after positive screening is critical to the clinical stratification and treatment process. Patients with SUD represent a subset of surgical patients who require a specialized, multidisciplinary approach aiming to improve both analgesic and perioperative outcomes. These patients should be identified prior to surgery for optimization and treatment, when appropriate. Postoperative care for patients with an active SUD can be challenging due to concerns for withdrawal symptoms, tolerance to analgesics, increased analgesic demand, negative surgical outcomes, and increased healthcare costs.13–15

    SUD is a major public health issue in the USA with an estimated 100,000 Americans dying every year due to opioid overdoses.16 In recent survey, over 19 million adults in the USA had at least 1 SUD, and almost 10 million opioid prescriptions were misused annually. SUD treatment accounted for US$38 billion per year in healthcare costs.17 18 Preoperative alcohol overuse can also negatively affect surgical outcomes, with a greater than 50% increase in postoperative general morbidity in risky alcohol users when compared with abstainers or non-risky users.19 The Alcohol Use Disorders Identification Test (AUDIT) tool can be used to screen for alcohol misuse or use disorder. Electronic access to the AUDIT screening tool as well as the commonly used ORT, SBIRT, TAPS1 and TAPS2, and 10-item Drug Abuse Screening Test are provided for reference in online supplemental appendix E.

    Due to under-reporting, the percentage of patients presenting to surgery with SUD is unknown; yet the majority of US surgical patients receive a postoperative opioid prescription.20 Screening for history of SUD or active SUD should ideally occur prior to the day of surgery and can be included during a surgeon’s preoperative or preanesthesia clinic visits. A positive screen indicates a potential SUD and triggers more in-depth screening and interventions such as counseling or referral to an addiction specialist or facility for a comprehensive evaluation and treatment if the patient is amenable.21 If an active SUD is identified on the day of surgery, the risk of postponing or proceeding with surgery should be carefully weighed by the perioperative care team and the patient.

    Principle 2: In conducting a preoperative evaluation, if a patient is identified to have chronic pain, opioid tolerance or substance use disorder clinicians should coordinate with the patient’s care team, including consultation with a pain medicine, behavioral health, or addiction medicine specialist.

    The first Pain Summit principles as well as other published guidelines highlight the importance of identifying patients with factors that increase perioperative pain care needs.1 22 When chronic pain, chronic preoperative opioid use or SUD is identified during the preoperative evaluation, a multidisciplinary approach should be initiated. Treatment planning includes the outpatient managing clinicians when applicable as well as the surgical team and potentially an anesthesiologist or pain specialist.23 24 If patients are identified to have chronic pain that is not managed, the surgical or preoperative evaluation is an opportunity to establish a patient–physician relationship for chronic pain care via referral.1

    Pre-existing pain is a risk factor for heightened acute postoperative pain and chronic postsurgical pain.25–27 Opioid tolerance is also associated with severe acute postoperative pain and chronic postsurgical pain.28 29 Patients with chronic opioid use represent 4%–23% of the general surgical population with certain patient populations, such as spine surgery, having chronic preoperative opioid use rates of 20%–55%.13 30 This patient factor contributes to poor postoperative outcomes, including a threefold increase in postoperative respiratory failure, increased surgical complications including infection, prolonged hospital stays, and readmission and higher healthcare costs.14 15 23 31–33 Concurrent benzodiazepine use nearly doubles 30-day mortality in patients undergoing non-cardiac surgery and predicts persistent postoperative opioid consumption.34

    When these factors are identified during surgical preparation or patient selection, anesthesiologists and pain specialists and their consult teams can detail pain management plans that span the perioperative period.35–38 Principles 3, 4, 5 and 6 discuss specific aspects of patient education and care coordination for patients on chronic opioids or with a history of chronic pain.

    Patients with SUD should be treated in a similar collaborative, multidisciplinary fashion with an emphasis on the use of opioid-sparing multimodal analgesia, expectation setting of analgesic goals, and cross-disciplinary care coordination.21 39–41 This approach allows for reconciliation of the patient’s outpatient medications on or before admission as well as detailing a stepwise approach for opioid weaning during the recovery phase.40 Preoperative evaluation of patients with SUD, aided when possible by an addiction medicine specialist, provides clear boundaries in a respectful and caring fashion while fostering accountability as the core of the management approach. Principle 7 discusses bolstering access to expert care via telemedicine for patients with chronic pain, preoperative opioid tolerance or SUD for patients who no longer have active management of these chronic issues but may benefit from such support during a period of surgical preparation and recovery.18 21 41 42 Patients with a history of SUD or active SUD can also have chronic pain and/or opioid tolerance. Similarly, patients with chronic pain may be at risk for a SUD but may not yet carry such a diagnosis.

    Principle 3: For patients on long-term opioid therapy preoperatively, clinicians should coordinate with the patient’s prescribing clinician and continue the baseline opioid dose in the perioperative period with supplemental analgesia as needed for postoperative acute pain.

    Successful treatment of patients on long-term opioid therapy involves timely planning with care coordination occurring between different clinicians involved in the patient’s perioperative and chronic care. There is evidence that under treatment of postsurgical pain is linked to reduced quality of life, delirium in elderly populations, surgical and cardiopulmonary complications, prolonged rehabilitation, chronic pain development and relapse in patients in recovery from SUDs.43 44 Abrupt discontinuation of opioids may cause withdrawal symptoms and/or increased pain.45 Awareness of this is critical to the care of patients on higher doses of short-acting opioids, most doses of long-acting opioids, medications for opioid use disorder (MOUD), and mixed opioid agonist-antagonists such as buprenorphine. These medications should be continued throughout the perioperative period, including throughout pregnancy, delivery, and in the postpartum period.44–47 These regimens are verified perioperatively via the patient’s self-disclosed medication and treatment history and/or available prescription drug monitoring data however methadone dosing for maintenance therapy may require direct communication with the dispensing treatment clinic as this data may not be reported to every state prescription databases. Formulary availability of the home agents should be confirmed to avoid unintentional gaps in therapy during hospitalization. The home regimen should be detailed as a part of the preoperative, intraoperative and postoperative multimodal therapy plans for the care team’s reference during and after the day of surgery.

    Pain services may offer evaluation for ‘pain clearance’ or optimization for elective procedures assisting in treatment planning, information gathering and patient education.48 49 Such care coordination specifies the potential multimodal treatment approaches that could be used including regional anesthesia and analgesia and medications such as non-steroidal anti-inflammatory medications, acetaminophen, gabapentinoids, alpha-2 agonists, muscle relaxants, local anesthetics, and ketamine. Approaches to home opioid regimen continuation and dose reduction or escalation can also be included in such evaluation.50

    Principle 4: Clinicians should work with patients who have opioid tolerance on an individualized tapering plan for postoperative opioids, coordinating with the long-term opioid-prescribing clinician, with the goal of return to the preoperative dose or lower as soon as possible.

    Coordination with patients’ outpatient prescribers help to characterize and optimize pain regimens perioperatively while acknowledging existing opioid agreements. For patients on chronic opioid therapy, transitions to postoperative and post discharge regimens include patient-specific prescription planning and timely scheduling of follow-up care and reevaluation. Coordination with preoperative prescribers facilitates appropriate timing of postoperative opioid dose tapering. Early follow-up with preoperative prescribers is associated with improved opioid safety after surgery and decreases the likelihood of unnecessary or concurrent prescription dispenses from multiple providers.51 Education on multimodal analgesic options and discussion of patient expectations perioperatively can improve patient satisfaction with the perioperative pain experience.52 In the hospital setting, this individualized approach couples dynamic patient assessment with multimodal analgesic strategies while minimizing risk. Particular attention needs to be given to subsets of patients at higher risk of tapering-related complications including pregnant or postpartum patients. The rate of postoperative opioid dose tapering should be individualized according to the patient and surgical procedure.53

    Perioperative or transitional pain services, when available, can also assist with opioid tapering after discharge. The use of such services reduces overall opioid consumption after surgeries, thereby preventing new chronic opioid use.36 54 For patients and clinicians finding opioid dose tapering to be challenging in the setting of preoperative opioid tolerance, consultation with pain medicine, behavioral health, or addiction medicine specialists should be used in lieu of persistent dose escalation and ongoing medication refills. The primary prescriber and surgical care team can collaborate to identify an aberrant trajectory of recovery and medication need.55

    Principle 5: For patients prescribed opioids at discharge following surgery, clinicians should inform them and their caregivers about the risks, signs and management of opioid-induced respiratory depression, that they must avoid concurrent use of medicines with sedative effects and alcohol while taking opioids, and when to call for emergency assistance.

    It is critical to educate and provide information to patients and their caregivers prior to discharge about the risk of respiratory depression, the signs and symptoms to watch for, and how to prevent and manage the symptoms of opioid-induced respiratory depression (OIRD. This approach aligns with multiple regulatory and compliance standards.

    Predictors of in-hospital postoperative opioid overdose include presence of obesity, renal disease, and most substantially, SUD.56 Most cases of OIRD occur in the first 24 hours after surgery but patients are still at risk up to 30 days post discharge.57–59 The risk of OIRD increases in patients with both acute or chronic pain with higher doses of daily morphine milli-equivalents (MME), especially over 100 MME daily.60 The risk of OIRD is increased in patients with underlying respiratory conditions such as chronic obstructive pulmonary disease or in patients taking concomitant central nervous system depressant medications such as benzodiazepines, gabapentinoids, zolpidem and zopiclone, or alcohol.61–64

    High-risk patients should be offered naloxone and caregivers should be aware of its role in reversing acute respiratory impairment and failure.65 Patients on chronic opioid therapy should be provided clear instructions as to how to take opioids after surgery. These instructions should seek to maximize non-opioid treatments as a foundation for postoperative pain control while reducing risk of opioid toxicity.22 Patients and caregivers should be provided information on using postoperative opioids as prescribed including avoidance of self-escalating dosing, the need to avoid alcohol and other sedatives, safe storage and proper disposal of unused medication. Patient and caregiver instructions should detail how to communicate with the clinical team if pain is uncontrolled, if side effects such as sedation, confusion or slowed breathing are experienced, the role of naloxone when prescribed, and what to do if naloxone is administered.65 A summary of resources on naloxone education are provided in online supplemental appendix F.

    Principle 6: For patients identified as at significant risk of opioid-related adverse drug events or severe uncontrolled perioperative pain, clinicians should consult a pain specialist or anesthesiologist preoperatively.

    Some predictors of high levels of postoperative pain include a history of or active SUD, OUD, preoperative opioid tolerance, or chronic pain. Patients on MOUD may require more involved perioperative analgesic planning for which specialist consultation can provide optimal analgesia while maintaining MOUD treatment.1 25

    Tools such as the American Society for Enhanced Recovery opioid-naïve, exposed, and tolerant+ criteria help assess opioid tolerance and risk of opioid-related adverse drug events (ORADEs).14 ORADEs such as respiratory depression or arrest and intensive care unit transfer can increase length of stay, hospital costs, readmissions, discharge to higher level of care, and mortality. Published studies suggest patient risk factors for ORADEs include: male sex; older age; concurrent benzodiazepine, alcohol, or sedative use. ORADE risk is associated with longer durations of surgery, inpatient intravenous opioid administration, and higher total inpatient opioid dosing.66–69 Patient comorbidities, as defined in various studies as higher ASA physical class, Elixhauser Comorbidity Score, Charlson Comorbidity Index, Medicare Severity-Diagnosis Related Group weight, are also associated with increased ORADE risk.66–69

    Consultation with and preoperative optimization by a pain specialist or anesthesiologist, preferably prior to the day of surgery, offers benefits such as improved care coordination, personalized analgesic options, medication titration, postdischarge tapering, and timely responsiveness to episodes of inadequate analgesia or medication side effects. ORADE history or elevated risk, MOUD therapy, or anticipated severe or difficult to control pain may indicate specialist consultation. A systematic approach at the institutional level simplifies and streamlines preoperative consultation of pain specialists or anesthesiologists for indicated patients.1 25 70

    Principle 7: For patients identified as benefiting from additional consultation with a pain medicine, behavioral health, or addiction medicine specialist, clinicians should utilize telehealth options if in person consultation is not available.

    Telehealth should be viewed as complementary to office visits and critical to addressing care gaps that arise in the perioperative care of patients with SUD, preoperative opioid tolerance, and chronic pain.71 Consultation for treatment optimization and care coordination is imperative and when in person consultation is not available clinicians should use telehealth options to similarly achieve these goals.

    The COVID-19 pandemic compelled physicians to integrate telehealth into their practice to maintain patient access to treatment. Many hospitals and practitioners have adopted this practice across the multiple sites of care in the care continuum in multiple specialties including pain management.72–74 Patients report high satisfaction with physician communication and care via telehealth visits.75 Centers for Medicare & Medicaid Services approval of coverage for behavioral health services as well as commercial and other insurance carriers enabled the delivery of this service during the COVID-19 pandemic. Multiple issues in implementation remain that limit the broad scale adoption of telemedicine for pain and perioperative care in the post-COVID-19 era.74 Information technology infrastructure, specialist availability, workforce shortages, disparities related to technologic literacy, and appropriate reimbursement all challenge further scaling and deployment. This care model offers to bring perioperative, behavioral, and pain specialist consultation to patients that need this care but may not have local, in person access prior to or after surgical care. The ability to provide such services across state lines is critical to ensure adequate access to patients in need but requires support of medical licensing boards and payors alike.

    Participants in this most recent Pain Summit project acknowledged that the scope of this project was not broad enough to encompass the perioperative care of patients with other important mental and behavioral health issues and that this is a limitation of this process. Based on the first Pain Summit, patients with chronic pain, SUD, and long-term opioid use were identified as ‘complex’ by the Consortium of participating organizations. Therefore, this second Pain Summit project focused solely on these surgical populations and recruited ASAM since the perioperative care of patients with SUD was not represented specifically by the existing Consortium organizations. We recognize that the spectrum of mental and behavioral health issues that may impact perioperative care is vast but critical to consider, and there may yet be a future Pain Summit to address this population.

    Conclusions

    In conclusion, the collaboration of 15 professional healthcare societies representing hundreds of thousands of physicians tasked daily with optimizing the care, outcomes, and experiences of patients undergoing surgical procedures creates a unique opportunity for alignment of vision and value. With a single voice, these principles create a ‘North Star’ for the surgical care of vulnerable patients at a time when communities face multiple unprecedented public health crises from prevalent rates of chronic pain and disability and rising deaths and harms from use of illicit substances as well as untreated SUD and substance misuse. The need to create awareness, advocacy, and education for safe and effective patient-centered surgical care is crucial to improving healthcare-related quality of life outcomes, especially for complex patients that standard approaches may underserve. This work is also an important step in understanding disparities and stigma, both of which are significant issues in the care of complex patients, people who deserve empathy and the appropriate level of care that will lead to the best possible outcomes.

    These results create a framework but require significant action. The societies engaged in this work have successfully completed two Pain Summits and consensus building processes from which implementation work can be launched collectively and within each organization’s membership. The need to hardwire these principles as directives within each society’s activities will drive the creation of reliable processes that can iterate and continuously improve. The dissemination of the principles from the previous consensus and Pain Summit and these new principles for complex patients throughout clinician circles is an important next step. Similarly, as team-based care is common in most ecosystems, the sharing and discussion of these principles with non-physician advanced practiced providers is necessary and will create significant value for patients and care teams. Collaborations in advocacy by the participant organizations for payor coverage of telemedicine services that are accessible to all patients and adequately reimbursed can provide a major change in patient access to specialist-based optimization perioperatively.

    The move from an alignment of ideas and principles to reliable process and improved outcomes is what comes next. The Consortium has the unique opportunity to continue to engage and innovate. To collectively improve through ongoing collaboration as a consortium in this format creates significant opportunity for the future.

    Data availability statement

    Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as online supplemental information. All data from the principle development process is available on request. The data have been shared in the text and supporting materials in its entirety.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants and was approved by NorthShore University HealthSystem IRB; EH22-476. Participants gave informed consent to participate in the study before taking part.

    Acknowledgments

    This material is the result of work, in part, supported with resources and the use of facilities at the Veterans Affairs Palo Alto Health Care System (Palo Alto, CA, USA). The contents do not represent the views of VA or the United States Government.

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    Supplementary materials

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    • Supplementary Data

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    Footnotes

    • Twitter @DMdickersonMD, @EMARIANOMD, @ShaliniShahMD, @ESchwenkMD, @garyschwartzmd

    • Contributors DMD, ERM, JWS, MH, JTM, AW and AB planned the project and Pain Summit, solicited volunteer participants, designed the survey instruments, contributed to data collection and interpretation, writing and revising of the manuscript, and final approval of the submitted manuscript. All other authors contributed to data interpretation, Pain Summit participation, writing and revising of the manuscript, and final approval of the submitted manuscript. As guarantor, DMD accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controlled the decision to publish.

    • Funding Logistical support was provided by the American Society of Anesthesiologists.

    • Competing interests DMD receives research support from Abbott and SPR therapeutics; speaker and/or consulting fees from Abbott, SPR Therapeutics, Vertos, Pfizer, Myovant, Nalu, and Biotronik; NME receives consulting fees for legal case review and from Pacira; SS receives consulting fees from SPR Therapeutics, Masimo Corp, and Allergan. GS receives consulting fees from Pacira and holds minor stake equity (stock options) in Dorsal Health; MS receives consulting fees and research support from Saluda Medical, consulting fees from Patch technologies, Witness, etc and iVitalie, and holds stock and/or receives consulting fees from Cellarian, Spark Biomedical, Nanomedical Systems, Full Spectrum Healthcare Management, MedAnswers, Reveliance solutions, and Assurance Med Management

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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