Acute Pain Management in Patients With Opioid Tolerance

Adebola Adesoye, PharmD, BCPS; Nakia Duncan, PharmD, BCGP, BCPS


US Pharmacist. 2017;42(3):28-33. 

In This Article

Abstract and Introduction


Prescription opioid use has significantly increased globally in the past two decades and has led to an increased number of patients who have become tolerant to opioids. Analgesia in this patient population poses a challenge, and there is a risk of undertreatment. In addition to providing effective analgesia, it is important to prevent withdrawal symptoms and address any related psychosocial issues. Therefore, a multidisciplinary and multimodal approach in pain management is necessary to provide effective analgesia in this patient population.


Prescription opioids are some of the most commonly prescribed pain medications in the United States, and they are usually the drugs of choice for managing moderate-to-severe pain. The number of opioids prescribed in the U.S. sky-rocketed from 76 million in 1991 to 216 million in 2012, with one-half of opioid sales accounting for treatment of chronic noncancer pain.[1,2]

The FDA defines a patient as opioid tolerant if for at least 1 week he or she has been receiving oral morphine 60 mg/day; transdermal fentanyl 25 mcg/hour; oral oxycodone 30 mg/day; oral hydromorphone 8 mg/day; oral oxymorphone 25 mg/day; or an equianalgesic dose of any other opioid.[3]Opioid tolerance implies a lesser susceptibility to the effects of opioids—both therapeutic and adverse—and it may develop in individuals with longterm use of opioids.[3–6] Patients who are prescribed opioids for management of cancer pain or chronic noncancer pain or who have an opioid addiction may become opioid tolerant.[5,6]

Acute pain may present postoperatively because of the traumatic surgical injury, or in other acute conditions. Acute pain in patients with opioid tolerance makes pain management a challenge, and perhaps one of the greatest risks associated with pain management in this population is the risk of undertreatment due to stigma and bias. Further, data on pain management in this patient population are limited.[7] This review focuses primarily on acute pain management in opioid-tolerant patients, including those with chronic opioid use for chronic noncancer pain and those who abuse opioids.