Clinical Review

Perioperative management of patients taking treatment for chronic pain

BMJ 2012; 345 doi: (Published 03 July 2012) Cite this as: BMJ 2012;345:e4148
  1. Conor Farrell, specialty trainee anaesthesia and pain medicine1,
  2. Paul McConaghy, consultant in anaesthesia and pain management 2
  1. 1The Ulster Hospital, Anaesthetic and Chronic Pain Department, Belfast BT16 1RH, UK
  2. 2Anaesthetic and Pain Management, Craigavon Area Hospital, Portadown BT63 5QQ, UK
  1. Correspondence to: Conor Farrell farrell_conor{at}
  • Accepted 28 March 2012

Summary points

  • Communicate with, and involve the patient in, perioperative management decisions

  • For opioids, continue baseline dose via appropriate route with additional supplementation for the acute event carefully titrated to the pain

  • For antidepressants, continue low dose tricyclic antidepressants, selective serotonin reuptake inhibitors, and selective noradrenaline reuptake inhibitors; be aware of potential for serotonin syndrome

  • For anticonvulsants, continue perioperatively; if stopping, taper the dose slowly to avoid withdrawal

  • If patient has a spinal cord stimulator, turn this off perioperatively

  • If patient has an intrathecal drug delivery system, continue perioperatively and supplement patient with additional analgesia for the acute event enterally and/or parenterally; be aware of potentially serious adverse effects of abrupt cessation of intrathecal medications

A large European survey conducted in 2003 found that 19% of adults report living with chronic pain.1 The British Pain Society defines chronic pain as pain that is continuous for more 12 weeks or (if the pain followed trauma or surgery) is longer than the time the healing would have been expected to take.2 Chronic pain, however, can be idiopathic, existing as its own disease entity, and does not need to have followed a specific traumatic or surgical event.

When patients with chronic pain are admitted to hospital, staff may be unfamiliar with the underlying condition and its management, potentially leading to a failure of staff to appreciate the need for continuation of regular analgesia as well as supplementation for acute postoperative pain. The presence of preoperative pain and high anxiety have been validated as predictors for early postoperative severe pain.3 Therefore, an inadequately managed patient with chronic pain risks experiencing severe postoperative pain. Providing effective analgesia is complicated by omission of regular medications owing to preoperative fasting,4 potentially leading to worsening of symptoms or development of withdrawal syndromes, while the prescription of …

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