Excerpts from one of Dr. Fisk’s articles:
“Pain psychologists offer yet another crucial avenue that must be explored. A recent study demonstrates the efficacy of cognitive behavioral therapy, especially problem-solving education, in helping with recovery from opioid addiction.[vi] A 2016 meta-analysis recognizes preoperative emotional distress to be strongly associated with postoperative pain, analgesic use, and impairment; pain catastrophizing, anxiety, and depression demonstrated stronger effect sizes.”
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“Concomitant psychiatric comorbidities are rampant in the opioid dependent including depression, anxiety, and other conditions, and often-times opioids play a role in affecting the course of these diseases. A 2014 publication analyzing successful maintenance of United States Veterans on a buprenorphine program demonstrates a markedly increase rate of non-compliance in those who have comorbid psychiatric illnesses.[vii] It is therefore imperative that psychiatrists help co-manage these individuals especially during an attempted reduction in opioid therapy. While many acute physical withdrawal symptoms last for only a few weeks, post-acute emotional withdrawal symptoms, including low energy, anhedonia, poor concentration, irritability, anxiety, and insomnia, can persist for months. This has substantial implications for perioperative optimization of these individuals.”
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“Physiological withdrawal responses cause sometimes excruciatingly unpleasant symptoms that can include insomnia, rhinorrhea, general weakness, sneezing, sweating, lacrimation, yawning, diarrhea, nausea, chills, abdominal pains, muscular pains, anxiety, irritability, and apprehension. Management of withdrawal symptoms involves a multitude of approaches including a slow opioid taper, often beginning with conversion to and subsequent reduction of methadone, and/or alpha-2-agonist symptomatic controlled taper. A recent Cochrane review of alpha-2-adronergic agonists for opioid withdrawal suggests that while methadone controlled taper is a slower process that reducing a patient’s non-methadone opioid in conjunction with the use of an alpha-2-adronergic agonist, the side effect profile is significantly less.[viii] Methadone pharmacokinetics are complex. Buprenorphine adds yet another level of complexity with its unusual pharmacodynamics properties including its very strong receptor avidity and ceiling effect. Addiction specialists, chronic pain specialists, and acute pain and regional anesthesia specialists have special training and knowledge with respect to these afore-mentioned physiological treatment modalities. Acute pain and regional anesthesia specialists especially are well-aware of the complexities of managing buprenorphine and methadone in perioperative patients, as well as the specific timing considerations before and after surgery with respect to re-initiation or continuation of these and other therapies. These specialists are also intimately familiar with alpha-2-agonists which are frequently used in IV form in the surgical population.”