Perioperative Pain Management: An Update on Pharmacology with a Special Focus on the Opioid Tolerant Elderly

With the increase in life expectancy in the United States, octogenarians and nonagenarians are seen more frequently in the perioperative period. The number of elderly patients undergoing surgery is increasing, paralleling the increasing use of opioids for chronic pain in the elderly population. In addition, many elderly patients have multiple preexisting comorbidities and a comprehensive list of home medications. These factors can make perioperative pain management complex, especially in patients with chronic pain and opioid tolerance. In this review, we collated available evidence for best practices in managing perioperative pain in the elderly, with a focus on pain management in the opioid tolerant patient.

Perioperative pain management can be challenging in elderly patients, especially those with opioid tolerance, given polypharmacy with potential subsequent drug-drug interactions. Based on the patient’s risk determined by the O-NET classification scheme, moderate to high-risk patients may benefit from a preoperative pain consultation prior to painful surgery.

Adequate analgesia needs to be balanced with dangerous side effects of sedation and respiratory depression in the elderly. Regional anesthetics and multimodal analgesics through their opioid sparing effect, may reduce overall opioid requirements; even though home doses of opioids for those on chronic opioids may need to be continued to prevent withdrawal.