Perioperative Pain Management in Patients Being Treated for Opioid Use Disorder: The Orthopaedic Surgeon's Role and Strategies for Comprehensive Care

Approximately 280,000 deaths in this country were attributed to opioid overdose between 1999 and 2021, increasing fivefold within this period. Orthopaedic surgeons have had a large contribution to this epidemic; they have been found to be the third highest prescribers of opioid medications. Multiple pharmacologic and nonpharmacologic treatment options for opioid use disorder (OUD) have been developed. The three most commonly used medications are methadone, buprenorphine, and naltrexone. In part owing to the use of these medications, states such as Oregon have seen a 20% decrease in opioid abuse and a 30% decrease in fatal overdoses. Historically, orthopaedic surgeons receive minimal formal training on managing postoperative pain in patients with OUD. Patients with OUD may experience neuroplastic changes from long-term exposure to opioids, which, in turn, diminish the analgesic effect of opioid medications in the acute postoperative period. Patients become more sensitive to painful stimuli, ultimately leading to loss of opioid efficacy. Undertreating pain may contribute to unnecessary patient suffering and can lead to mistrust within the patient-physician relationship. Overtreating pain may have catastrophic consequences such as disruption of sobriety, respiratory compromise, and death. It is recommended to include a pain management specialist or service during the perioperative period, if possible. This article clarifies the orthopaedic surgeon's role in the perioperative care of this patient population by providing an overview of medications used to treat OUD, pain control strategies, psychosocial concerns, and legal considerations, with the goal of streamlining care to improve patient safety and outcomes.