Medical science has witnessed a dramatic shift in the awareness and treatment of chronic pain over the past few decades. Numerous organizational and regulatory bodies have declared pain as the fifth vital sign to encourage physicians to actively pursue and treat pain problems. Moreover, expansion in life expectancy has caused a relative increase in the elderly population, which carries the brunt of chronic pain problems. Given this scenario, it is not uncommon for anesthesiologists to encounter patients who are taking opioids. Some of them are on certain colossal doses that widen our eyes. Lack of knowledge on our behalf, bundled with uncertainty about opioid dose requirements and expectations of a smooth perioperative course by family and the surgical team, certainly make these cases challenging. These difficult situations can be handled with poise by knowing some fundamental principles related to the perioperative care of chronic opioid-dependent patients.

Anesthetic care of these intricate cases begins with early recognition of opioid-tolerance issues (Table 167.1) and formulation of a clear plan. A preoperative visit allows the anesthesiologist to perform a thorough medical evaluation, outline a postoperative pain management plan, and advise on therapeutic options. Information about the patient’s opioid and adjuvant medication doses should be gathered. An electrocardiogram should be obtained to look for any QT interval prolongation, which is sometimes seen with the use of high doses of methadone. Prolongation of the QT interval is also seen with tricyclic antidepressant medications, which are frequently used as adjuvant drugs in chronic pain patients. A prolonged QT interval can predispose a patient to ventricular tachycardia, ventricular fibrillation, or torsades de pointes, and must be identified. A detailed discussion should be had with the patient to address his or her anxieties and fears. Patients are often worried about excessive pain following the surgery, which is frequently a reflection of their previous experiences. Anesthetic management options should be discussed. Whenever possible, a regional anesthetic technique should be chosen and explained to the patient.