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Key messages
1. Opioid‐tolerant patients report higher pain scores and have a lower incidence of opioid‐
induced nausea and vomiting (U) (Level III‐2).
2. Ketamine improves pain relief after surgery in opioid‐tolerant patients (N) (Level II).
3. Opioid‐tolerant patients may have significantly higher opioid requirements than opioid‐
naive patients and interpatient variation in the doses needed may be even greater (N)
(Level III‐2).
4. Ketamine may reduce opioid requirements in opioid‐tolerant patients (U) (Level IV).
The following tick boxes represent conclusions based on clinical experience and expert
opinion.
Usual preadmission opioid regimens should be maintained where possible or appropriate
substitutions made (U).
Opioid‐tolerant patients are at risk of opioid withdrawal if non‐opioid analgesic regimens
or tramadol alone are used (U).
PCA settings may need to include a background infusion to replace the usual opioid dose
and a higher bolus dose (U).
Neuraxial opioids can be used effectively in opioid‐tolerant patients although higher doses
may be required and these doses may be inadequate to prevent withdrawal (U).
Liaison with all health care professionals involved in the treatment of the opioid‐tolerant
patient is important (U).
In patients with escalating opioid requirements the possibility of the development of both
tolerance and opioid‐induced hyperalgesia should be considered (N).
11.8 THE PATIENT WITH AN ADDICTION DISORDER
An addiction disorder exists when the extent and pattern of substance use interferes with the
psychological and sociocultural integrity of the person (see Table 11.7 above). For example,
there may be recurring problems with social and personal interactions or with the legal
system, recurrent failures to fulfil work or family obligations, or these patients may put
themselves or others at risk of harm.
Use of the term addiction is recommended in the consensus statement from the American
Academy of Pain Medicine, the American Pain Society and the American Society of Addiction
Medicine (AAPM et al, 2001), even though the alternative term substance dependence is used CHAPTER 11
by other health organisations (Ballantyne & LaForge, 2007). This separates the behavioural
component (addiction) from tolerance and physical dependence. The latter two factors are
likely to exist if a patient is taking opioids long‐term, but may not be present in all patients
with an addiction disorder; it also reduces the risk of stigmatisation of patients who have a
physical dependence because of long‐term opioid therapy (Ballantyne & LaForge, 2007).
Effective management of acute pain in patients with an addiction disorder may be complex
due to:
• psychological and behavioural characteristics associated with that disorder;
• presence of the drug (or drugs) of abuse;
• medications used to assist with drug withdrawal and/or rehabilitation;
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