Postoperative pain outcomes following minor oral surgery in opioid tolerant patients: a retrospective cohort study

Background Evidence guiding postoperative pain management in patients taking prescription or illicit opioids undergoing minor oral surgery is limited. It remains unclear whether standard analgesic protocols for opioid naïve patients provide adequate pain relief in opioid tolerant individuals. This study evaluated whether standard postoperative analgesia achieves adequate pain control in opioid tolerant patients undergoing minor oral surgery with expected mild to moderate pain. Methods A single centre retrospective study was conducted of patients undergoing minor oral surgical procedures at a public oral surgery service between May 2020 and May 2024. Patients were classified as opioid tolerant if prescribed opioids for longer than one month, receiving methadone therapy, reporting current illicit opioid use, or having a documented history of opioid use disorder. Opioid naïve patients served as controls. Standard postoperative analgesia consisted of paracetamol and non-steroidal anti-inflammatory drugs unless contraindicated. The primary outcome was return with postoperative pain requiring additional opioid analgesia. Results A total of 1,263 patient records met inclusion criteria, including 184 opioid tolerant and 1,079 opioid naïve patients. Opioid tolerant patients were significantly more likely to return with postoperative pain requiring additional opioid analgesia compared with opioid naïve patients (28.8% vs. 2.2%; adjusted OR 24.59, 95% CI: 13.26–45.62; p < 0.001). This association remained consistent across demographic subgroups and extraction types. Conclusions Current post operative analgesic pathways may not fully address the analgesic requirements of some opioid exposed patients. This study demonstrates that opioid tolerance is associated with an increased risk of return presentation requiring additional opioid analgesia. Clinical relevance Opioid tolerance is associated with an increased risk of inadequate postoperative pain control, highlighting the need for tailored analgesia beyond standard regimens.