Perioperative Chronic Pain Management
Feb 28, 2025
Soothing the Beast - perioperative chronic pain management π₯ππ©Ί
Chronic pain affects 3.4 million Australians π¦πΊ, with 1 in 6 Australians suffering from chronic lower back pain π¦΅. It is inevitable π, and relatively common for perioperative patients to have an underlying chronic pain prior to their surgery π₯. So how do we manage it best? π€ Here are some key considerations for the perioperative management of chronic pain:
π©Ί Baseline pain levels:
Those living with chronic pain live with a baseline level of pain, which is important to understand prior to commencing surgery. Determine how severe their day to day pain is e.g. a patient may tell you their baseline level of pain is 5/10.
It is also important to understand whether this is a constant pain level, or if there are fluctuations in their pain and what triggers or exacerbates their pain.
π Baseline analgesia:
It is critical to determine a patient’s analgesia regime prior to surgery (if any) in order to plan for adequate post-operative pain management.
At a minimum, baseline analgesia should be maintained for the patient - the immediate post-operative period is not the time to be weaning long-term analgesia!
π§βοΈ Explore non-opioid analgesia options:
Depending on the type of surgical procedure the patient is having, emphasis should be placed on non-opioid options for pain management, such as local anaesthetic and regional/neuraxial techniques, Ketamine and other opioid-sparing adjuncts such as clonidine.
π Post-operative opioids:
Many chronic pain patients will have a degree of opioid tolerance prior to their surgery. In the post-operative phase, it is reasonable to expect that these patients will require higher amounts of opioid to achieve an analgesic effect due to this tolerance. This only reinforces the emphasis on non-opioid analgesia options for this patient cohort.
π©Ί Post-operative pain assessment:
When assessing post-operative pain, it is important to distinguish between the acute post-surgical pain and the underlying chronic pain. Consideration must be given to the patient’s baseline level of their chronic pain, understanding that it is unlikely that this can be improved upon in the perioperative environment. If a patient’s baseline level of pain is 5/10, then this becomes the new goal post that we are aiming for.
π Ongoing plan:
It is so important to ensure that there is a clear, ongoing management plan outlined for the ward and treating team, incorporating multimodal analgesia options.
As much as we would love to treat ALL of the patient’s pain, it is not a realistic expectation of the perioperative phase. Our goal is to maintain the patient’s regular chronic pain management regime, and treat the acute post-surgical pain.
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References:
Pain Australia (2020) https://www.painaustralia.org.au/about-pain/painful-facts#:~:text=Prevalence,million)%20are%20of%20working%20age.
Simpson, G.K., Jackson, M. (2017) Perioperative management of opioid-tolerant patients. BJA V17(4) pp 124-128. DOI: 10.1093/bjaed/mkw049
Vadeghani, A.T., Grant, M. & Forget, P. Perioperative pain management interventions in opioid user patients: an overview of reviews. BMC Anesthesiol 24, 310 (2024). https://doi.org/10.1186/s12871-024-02703-6
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