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There is an increasing number of patients with a background of chronic pain presenting to the otolaryngologist. Patients with chronic pain require extra consideration in postoperative pain control due to risk of tolerance and dependence. This article summarises postoperative management of these patients. In patients with chronic opioid use, it is important to note that they may have increased analgesia requirements due to tolerance. The authors suggest patients continue their usual baseline analgesia on the day of surgery and after surgery with additional supplemental opioids. Multimodal analgesia is key, using regional anaesthesia and other non-opioid group of medications to complement each other. NSAIDs and paracetamol should be offered for all patients if there are no contraindications such as gastrointestinal bleeds/ulcers and chronic liver disease, respectively. Topical anaesthetics such as lignocaine infiltration/patches and capsaicin cream can be used as well, with capsaicin useful in patients with neuropathic and musculoskeletal pain. Of note, there is a subset of patients that subsequently go on to develop chronic pain. This is believed to be secondary to increased sensitisation of noxious stimuli around the injured tissue. Patients at risk of developing chronic pain include preoperative pain levels, operative nerve injury, procedures lasting more than three hours, site of surgery and psychosocial factors. With early identification of this at-risk group of patients, managing acute pain well and setting realistic expectations could help prevent development of chronic pain. This article also covers pain management for patients on methadone therapy. After initially maximising non-opioid analgesia, short acting opioids are recommended in addition to usual methadone dosing. Long-term opioids should be avoided as it could lead to opioid tolerance and opioid-induced hyperalgesia. It is not uncommon that patients on methadone therapy require higher and more frequent doses of short-acting opioid analgesics to obtain adequate pain control in the immediate postoperative period. Overall, this article has been very useful in providing a general guide in management of patients with chronic pain following surgery.

Postoperative analgesia in the chronic pain patient.
N Grancaric, W Lee, M Scanlon.
OTOLARYNGOL CLIN NORTH AM
2020;53(5):843-52.
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CONTRIBUTOR
Wai Sum Cho

University Hospitals of Leicester, UK.

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