Perioperative pain management interventions in opioid user patients: an overview of reviews

Abstract

Background

Every year, many opioid users undergo surgery, experiencing increased postoperative complications, inadequate pain control, and opioid-related adverse effects. This overview aims to summarise and critically assess the systematic reviews about perioperative pain management interventions, identify the knowledge gaps, and potentially provide high-quality recommendations to improve postoperative analgesia and surgical outcomes.

Methods

A systematic search was conducted from the following databases, PubMed, Cochrane Database of Systematic Reviews, Embase, APA PsycINFO, CINAHL, AMED, Scopus, PROSPERO, ProQuest, and Epistemonikos, in June 2023. Additionally, reference lists were reviewed. The identified studies were assessed based on eligibility criteria and data extracted by a self-designed form and two independent reviewers. Qualitative data were synthesised, and all included studies were assessed by The Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) checklist.

Results

Nine studies were included. The methodological quality of the studies was mostly critically low. Various interventions were identified, including perioperative management of buprenorphine, ketamine administration, multimodal analgesia, higher doses of medications, patient education, and interprofessional collaboration. The level of certainty of the evidence ranged from very low to high. One high-quality study showed that ketamine administration may improve perioperative analgesia supported with moderate to very low-quality evidence, and low and critically low studies indicated the efficacy of perioperative continuation of buprenorphine with low to very low-quality evidence.

Conclusion

Perioperative continuation of buprenorphine and ketamine administration as a multimodal analgesia approach, with moderate to very low-quality evidence, improves pain management in opioid users and decreases opioid-related adverse effects. However, high-quality systematic reviews are required to fill the identified gaps in knowledge.

Introduction

Background

Chronic opioid users consist of patients with opioid use disorder (OUD) on medication treatment (MOUD) such as buprenorphine, methadone, and naltrexone, those without pharmacological treatment, and patients who use prescribed opioids for chronic pain [1]. International Statistical Classification of Disease and Related Health Problems, 11th revision (ICD-11) suggests Disorders Due to Use of Opioids definition, including Opioid Dependence [2]. However, OUD is the preferred terminology by the Diagnostic and Statistical Manual-5 (DSM-5) [3]. Additionally, the O-NET classification system defines preoperative opioid tolerant as patients who used ≥ 60 mg morphine equivalent dose within seven days before the surgery [4].

In 2019, 8.3 million people were identified with illicit drug use and 1.6 million with prescription analgesic use disorder in the US [5]. Additionally, 310 million patients undergo surgery yearly [6] which 4-23% are chronic opioid users [7, 8]. Preoperative chronic use of opioids is associated with an increased risk of postoperative complications, such as respiratory failure, surgical site infection, induced mental disorder, readmission, and increased costs [7, 9,10,11]. These patients experience higher acute postoperative pain levels [12] and increased risk of postoperative chronic pain [13]. Even chronic administration of low-dose opioids may induce hyperalgesia and increase postoperative opioid consumption [14]. There are several guidelines to enhance surgical outcomes and pain management; however, There is a need to continually update existing guidance on this complex topic when high-quality evidence becomes available.

Aim

This overview of systematic reviews summarises and critically assesses the quality of systematic reviews related to perioperative pain management interventions in opioid users. It also aims to identify knowledge gaps to help future research and possibly provide a list of high-quality recommendations for clinical practice to optimise pain management and surgical outcomes.

Methods

Review design

This overview of reviews was conducted based on the Reporting guideline for overviews of healthcare interventions: the Preferred Reporting Items for Overviews of Reviews (PRIOR) statement [15]. Ethics approval was not required for this literature-based project. Also, a predetermined protocol could not be registered in PROSPERO based on methodological criteria.

Eligibility criteria

The eligibility criteria are shown in Table 1. In this overview, a systematic review was defined as any review that conducted a systematic search strategy and the authors mentioned it within their papers.

Table 1 Summary of eligibility criteria

Search strategy

The search strategy involved the following databases: PubMed, Cochrane Database of Systematic Reviews, Embase, APA PsycINFO, CINAHL, Allied and Complementary Medicine (AMED), Scopus, PROSPERO/International Prospective Register of Systematic Reviews, ProQuest Dissertations & Theses A&I, and Epistemonikos, from inception until June 2023. The results were limited to English language and systematic review study design. Google Scholar was also hand-searched for related systematic reviews. The search included “opioid users” and “perioperative pain management” keywords. The details of the search strategy for each database are provided in Appendix 1. Furthermore, the reference lists of included studies were reviewed.

Study selection

Rayyan AI [16] was used to manage the studies. Duplicates were automatically detected, manually screened, and deleted. Two independent reviewers screened the results by titles and abstracts. Irrelevant studies were eliminated. Then, the full text of the studies was screened based on eligibility criteria. Any questions or uncertainties were addressed and resolved through discussion and consensus among the two reviewers and third one.

Data collection

A self-designed data extraction form was used to manually collect data from included studies. This form consisted of the following items: author, title, year of publication, country, search period, number of primary studies included, total number of participants, aim, population, intervention, primary outcomes, study designs, funding sources, quality evaluation method, degree of certainty, conduct of meta-analysis (yes/no), study limitations, areas for future research, and main findings. Data collection was done by two reviewers independently and any disagreement was resolved by consensus. Data collection was done by two reviewers independently and any disagreement was resolved by consensus.

Quality assessment

The Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) checklist was used to assess the methodological quality of the reviews included by two independent reviewers [17]. This checklist consists of 16 items (Appendix 2) and presents the overall rating based on weaknesses in the critical domain in the form of the following categories, high (≤ 1 non-critical weakness), moderate (> 1 non-critical weakness), low (1 critical flaw with or without non-critical weaknesses), critically low (> 1 critical flaw with or without non-critical weaknesses). The authors of the included reviews were contacted to provide complementary data. The results were presented with all questions and overall ratings in a table.

Data synthesis

The data were synthesised qualitatively and presented as a summary table. The interventions used by each review were extracted and categorised, and a narrative synthesis of the results was conducted.

Results

Study selection

Electronic searches of ten databases were conducted, and ProQuest and APA PsycINFO had no results regarding the search strategy. In total, 699 studies were identified. After removing the duplicates and adding other identification methods results, 412 studies were screened with titles and abstracts. Three hundred and ninety-two studies were excluded (Fig. 1). Twenty studies were retrieved and screened in full text by eligibility criteria, and 11 studies were excluded. Three studies did not cover perioperative pain, and eight had the wrong study design (Appendix 3). Finally, nine studies were included in the overview (Table 2).

Fig. 1

PRISMA flow diagram. This figure demonstrates the study selection process based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram [18]

Study characteristics

Most systematic reviews were conducted in the USA (n = 5), and only one European country (Germany) was identified [19]. While one study was conducted in 2014 [20], the remaining studies were published between 2019 and 2022. Additionally, two studies did not report the search date or their last update [4, 21]. Only Meyer-Frießem et al. conducted a meta-analysis [19], and three of the studies were scoping reviews that used systematic search strategies [20, 22, 23]. Furthermore, Edwards et al. and Quaye et al. used their reviews to identify available studies associated with perioperative pain management interventions followed by consensus recommendations [4, 23]. Against inclusion criteria, Veazie et al. included all causes of acute pain; however, 66.7% of their included studies were exclusively focused on perioperative pain management, and the remaining covered non-specified acute pain [24]. Mehta et al., Edwards et al., and Veazie et al. restricted their populations to adults (≥ 18 years) [4, 24, 25], and Lim et al. only investigated pregnant patients [22]. In terms of opioid user definition, Meyer-Frießem et al. and Edwards et al. included all opioid users [4, 19]. Four studies restricted their reviews to patients on MOUDs, particularly buprenorphine [23,24,25,26]. One study only included randomised clinical trials (RCTs), while others included any designs. Four reviews included various interventions. Others were more specific, with one study focused on perioperative ketamine administration and four studies comparing the continuation and discontinuation of buprenorphine, one of which also included other MOUDs modifications. The reviews included 9–84 studies, and only two reported the total number of participants [19, 25]. The studies checked for various and heterogeneous outcomes. Some of them did not mention their outcomes clearly. However, most reviews considered the adverse effects and efficacy of interventions via scoring pain, opioid consumption, and risk of OUD.

Table 2 Studies characteristics

Risk of bias in the reviews

Less than half of the reviews (4/9) reported their risk of bias or quality of evidence assessment. Meyer-Frießem et al. used Cochrane’s Risk of Bias 2 (ROB2.0) and reported the results in detail. Most of their primary studies had a high risk of bias and only one had uncertain risks. They also used the Grading of Recommendations Assessment Development and Evaluation (GRADE) for quality of evidence assessment and reported the following results: moderate (n = 1), low (n = 3), and very low (n = 4) quality [19]. Edwards al. also employed GRADE and reported the results with A to C, levels one to four, and moderate to very low [4]. French et al. used the Study Quality Assessment Tools of National Heart, Lung, and Blood Institute (NHLBI) that resulted in good to poor quality primary studies (good: n = 8, fair: n = 2, poor: n = 1). The authors only reported the assessment of 44% of studies (11/25) [21]. Veazie S et al. employed Cochrane’s Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool, modified with the CAse REport (CARE) checklist for observational studies without control groups. Three of their primary studies had a high risk of bias, nine were partly reported, and one was mostly reported regarding the quality of reporting of evidence [24].

Quality of evidence

The AMSTAR2 checklist was used for the quality of evidence assessment of included reviews [17]. Most reviews had critically low quality (7/9 studies) [4, 20,21,22,23, 25, 26]. One study was rated as low quality [24], and only one study achieved high methodological quality [19]. Despite emailing eight authors to provide more data, none of them responded. None of the studies contained all AMSTAR2 items. Almost all authors defined PICO adequately and explained their rationale behind study selection [4, 19, 21,22,23,24,25,26]. However, one study did not mention the comparators in the eligibility criteria [20]. While all the authors declared their funding sources and conflicts of interest, none of them reported the funding sources of their primary studies. Most authors comprehensively reported the literature search strategy; however, searching for grey literature and clinical trials, using experienced consultants in the field, and conducting the search within 24 months of completing the review were not reported in many reviews. Only one of the authors reported the search strategy completely [24]. Moreover, most reviews selected and reviewed the studies in duplicate [4, 19, 20, 22, 24,25,26]. Only one author reported the excluded articles with the reason for exclusion [19]. Also, Items 2, 7, 9, 13, and 14 were not reported in most reviews (Table 3).

Table 3 Quality assessment results [4, 19,20,21,22,23,24,25,26]

Main findings

Perioperative buprenorphine management

Four included studies focused on buprenorphine management, and three more investigated it as part of their review. All studies recommended continuing buprenorphine perioperatively, but two reviews suggested a reduced daily dose (Table 4). Goel et al. found no evidence supporting the harm reduction of buprenorphine discontinuation in the perioperative period. They concluded that if the daily dose of the sublingual form of medication is ≤ 16 mg, it can be continued without more harm. However, for patients with a higher risk of addiction relapse, discontinuation of buprenorphine should be assessed carefully based on patient and surgery considerations. Three studies reported reduced postoperative opioid consumption with buprenorphine continuation [22, 24, 26]. Quaye et al. showed that perioperative continuation of buprenorphine does not increase the risk of adverse effects, and patients who interrupted buprenorphine have a higher risk for postoperative OUD relapse, illicit opioid use, opioid withdrawal symptoms, and amplification of chronic pain. They recommended buprenorphine continuation with a reduced dose to optimise the analgesic effects of opioid agonists and prevent withdrawal symptoms and proposed an algorithm for major surgery [23]. Mehta et al. reported the range of buprenorphine daily dose 2–32 mg associated with various multimodal analgesia strategies. Their review identified that pain management in patients on MOUD is more challenging than without it [25]. Veazie et al. confirmed others’ findings and suggested that insufficient pain management may increase the risk of discontinuation of MOUD treatment [24]. Lim et al. emphasised the low quality of the studies and identified knowledge gaps (Table 5) [22]. There are overlaps of primary studies among Lim et al., Goel et al., and Mehta et al. reviews that resulted in similar findings and recommendations [22, 25, 26]. Buckley et al. and Edwards et al. also recommended continuation of MOUDs [4, 20].

Table 4 Summary of findings associated with continuation of buprenorphine perioperatively

Table 5 Summary of areas for future research

Perioperative administration of ketamine

Meyer- Frießem et al. investigated the efficacy of perioperative administration of ketamine (Table 6). They conducted a high-quality systematic review and meta-analysis; however, the quality of evidence regarding their outcomes was moderate to very low. They showed that perioperative administration of ketamine may decrease postoperative pain during the movement, opioid-related side effects, and total opioid consumption within 48 h after surgery. They recommended considering ketamine in the pain management strategies of opioid users. The range of ketamine doses was 0.15–0.5 mg/kg for bolus injection and 0.002 mg/kg/h-0.25 mg/kg/h for maintenance infusion [19]. Furthermore, French et al. recommended using ketamine infusion as a part of the multimodal analgesia approach in patients with methadone maintenance therapy [21]. Edwards et al. highlighted that the efficacy of ketamine is dependent on the dose of ketamine and the type of surgery [4].

General interventions

Multimodal analgesia has been recommended by most of the reviews as a combination of different approaches, including the administration of NSAIDs, paracetamol, dexamethasone, lidocaine, alpha2 agonists, gabapentinoids, and N-methyl-D-aspartate (NMDA) receptor antagonists [20,21,22,23,24,25]. Quaye et al. showed that these approaches improve analgesic efficacy [23]. Edwards et al. also concluded with a high degree of certainty that the multimodal analgesia approaches, a combination of opioid and nonopioid analgesics, regional analgesia, and nonpharmacological treatments, optimise pain management and reduce the associated adverse effects. However, they didn’t identify evidence supporting nonpharmacological treatments’ efficacy, including distraction therapy, music therapy, hypnosis, and transcutaneous electrical nerve stimulation. Additionally, Edwards et al. recommended that prescribing opioids should be conditional to insufficient pain management by nonopioid analgesics, and individualised minimum effective doses and tapering opioids collaborating with the patient’s outpatient provider should be considered [4]. This study also recommended weaning opioids preoperatively to the minimum effective dose based on the patient’s condition and its feasibility.

Moreover, the findings of French et al., Veazie et al., Lim et al., and Mehta et al. showed that patients who use opioids chronically required higher doses of analgesics to control postoperative pain effectively but only with low-quality evidence. [21, 22, 24, 25]. French et al. and Quaye et al. recommended an interprofessional collaboration among addiction and pain specialists, nurses, anaesthesiologists, surgeons, psychiatrists, and patients [21, 23]. Patient education and awareness of potential adverse effects and realistic postoperative pain also play critical roles in the effectiveness of pain control and managing patient expectations [4, 21, 23].

Pregnancy

Lim et al. and Buckley et al. focused on peridelivery pain management in opioid users [20, 22]. However, the primary studies had low-quality evidence, leading to numerous knowledge gaps (Table 5). Since most reviews used pregnant and caesarean cases for buprenorphine management, the detailed results and recommendations were mentioned in the corresponding previous sections.

Table 6 Summary of findings associated with general interventions

Discussion

Main findings

This overview summarised the latest findings of systematic reviews associated with perioperative pain management interventions in the opioid user population. The review included several studies, with the majority having critically low methodological quality and only with high quality [19]. The level of certainty of the evidence ranged from very low to high. The high-quality review demonstrated that opioid users may benefit from perioperative administration of ketamine with moderate to very low-quality evidence [19]. Additionally, low and critically low systematic reviews revealed that perioperative continuation of buprenorphine may improve postoperative analgesic outcomes with very low to low-quality evidence [4, 20, 22,23,24,25,26]. Furthermore, critically low systematic reviews demonstrated the effectiveness of multimodal analgesia approaches, including the combination of opioid and nonopioid analgesic, regional analgesia, and nonpharmacological treatments for pain management, which the quality of their evidence is not available [4, 20, 21, 23,24,25]. Requirement for patient education, interprofessional collaboration, and higher doses of medication are other main findings.

Most included reviews were conducted within the past few years, indicating a recent increase in efforts to fill the knowledge gap in this field. Clinicians may benefit from this overview as it summarised and appraised currently used interventions’ quality of evidence. It helps them decide the optimal analgesia strategies based on the patient’s conditions and type of surgery. Also, this overview revealed the gaps in knowledge in the field and the necessity of designing and conducting high-quality studies. Despite the low quality of systematic reviews and their primary studies, perioperative continuation of MOUDs, particularly buprenorphine, remains clinically relevant. Implementation of individualised multimodal analgesia strategies, especially the administration of ketamine, is also highly recommended. The findings and expert opinions suggest prioritising opioid-sparing analgesics over postoperative opioids and, if opioids are needed, using them with minimum effective dose based on the patient and surgical considerations. It should be considered that tapering the postoperative opioids in this population is critical for enabling patients to return to their baseline preoperative opioid doses, but the way to achieve it remains to be demonstrated.

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, Acute Pain Management fifth edition, emphasises the continuation of buprenorphine perioperatively. It suggests that dividing the daily dose of buprenorphine into 2 or 3 doses may improve pain management. This guideline also recommends following the “universal precautions” for OUD patients, including multimodal analgesia, abuse-deterrent formulations, utilization of prescription drug monitoring programs, and risk management strategies. Additionally, it recommends ketamine to improve pain management in opioid-tolerant patients [27]. Recently published multiorganizational consensus from the US Health and Human Services Pain Management Best Practices Inter-Agency Task Force also recommended similar principles [28]. The UK Surgery and Opioids, Best Practice Guidelines 2021 suggest preoperative opioid users as complex cases requiring an individualized plan. This guideline recommends considering preoperative opioid weaning if feasible in selected cases [29]. A retrospective matched cohort study identified improved postoperative functional outcomes in opioid tolerant patients who reduced their preoperative morphine equivalent dose by at least 50% versus those who did not, after total joint arthroplasty [30]. These authors suggest early risk/benefit discussions with patients contemplating joint arthroplasty, with possible referral to pain specialists or primary care providers for interested patients. Otherwise, the opioid should be continued perioperatively. For patients on MOUD, an individualised plan is required. Although there is consensus that buprenorphine should be continued perioperatively, some institutions recommend a dose adjustment preoperatively for surgeries with moderate to high risk of postoperative pain [31].

Limitations

The following potential limitations may impact the quality of this overview. Employing the systematic review filter in the search strategy may lead to losing some of the reviews which are not defined as systematic reviews but are eligible based on the criteria. Because PICO (Population, Intervention, Comparison, and Outcomes) is not clearly identified in scoping reviews, the AMSTAR2 tool may not be the ideal appraisal checklist for them. Furthermore, this overview has relied on the included reviews’ quality assessment, results, and data interpretation, which mostly have critically low methodological conduction. If complementary data were available, the results of AMSTAR2 would be more reliable. Additionally, using one reviewer instead of two independent reviewers for study selection and data extraction steps, no assessment for overlapped primary studies, and no re-assessment of quality evidence for all primary studies may limit the results of this overview.

Future research

One of the noticeable gaps in this field is the lack of high-quality studies, in particular randomised controlled trials. Trials should consider patient-important outcomes such as quality of life and patient satisfaction, the risk of relapse of OUD, and opioid-related side effects, including depression, sedation, and respiratory suppression (Table 5). Studies with longer follow-ups to assess long-term outcomes, including morbidity and mortality, are also required. Future studies should compare various interventions and doses in the population and present data with more details to suggest the optimal doses of the MOUDs and postoperative analgesics. Furthermore, since most of the included reviews had critically low quality, there is a gap for up-to-date systematic reviews focusing on the specific interventions to capture recent studies that might be missed by the included reviews and conducted with high methodological quality. Moreover, the efficacy of nonpharmacological strategies, multimodal analgesia, and perioperative management of methadone and naltrexone should be considered.

Conclusion

This overview showed that perioperative continuation of buprenorphine and implementation of multimodal analgesia, particularly administration of ketamine, is recommended to improve pain management and reduce opioid-related adverse effects and OUD relapse. However, most of the available systematic reviews about perioperative pain management interventions in chronic opioid users have critically low methodological quality. In the future, high-quality primary studies, especially randomised clinical trials, are required. These studies should focus on optimal analgesic doses, patients-important and long-term outcomes, and the best analgesia strategy.

Appendices

Appendix 1

Search strategy

PubMed (NCBI): June 10, 2023

Search	Query	Records retrieved
#1	“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”	500,307
#2	“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”	53,308
#3	#1 AND #2	4,484
	Limited to systematic review, meta-analysis, humans, English [lang]; no date limits	120

Cochrane Database of Systematic Reviews (Ovid): June 10, 2023

Search	Query	Records retrieved
#1	“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”	1,219
#2	“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”	193
#3	#1 AND #2	49
	no date limits	49

Embase (Ovid): June 10, 2023

Search	Query	Records retrieved
#1	“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”	308,119
#2	“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”	68,785
#3	#1 AND #2	6,231
	Limited to systematic review, review [publication type], humans, English [lang]; no date limits	110

APA PsycINFO (Ovid): June 10, 2023

Search	Query	Records retrieved
#1	“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”	24,639
#2	“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”	24,698
#3	#1 AND #2	1,009
	Limited to systematic review, humans, English [lang]; no date limits	0

CINAHL (EBSCO): June 9, 2023

Search	Query	Records retrieved
#1	“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”	69,030
#2	“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”
#3	#1 AND #2	1,761
	Limited to systematic review, humans, English [lang]; no date limits	61

Allied and Complementary Medicine (Ovid): June 10, 2023

Search	Query	Records retrieved
#1	“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”	3,648
#2	“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”	489
#3	#1 AND #2	127
	Limited to review, English [lang]; no date limits	7

Scopus (Elsevier): June 10, 2023

Search	Query	Records retrieved
#1	TITLE-ABS-KEY (“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”)	277,024
#2	TITLE-ABS-KEY ( “opioid user*"  OR  “opiate user*"  OR  “drug user*"  OR  “drug abuser"  OR  “OUD"  OR  " opioid use disorder"  OR  “LTOT"  OR  “long term opioid therapy"  OR  “opioid tolera*"  OR  “chronic opioid use"  OR  “preoperative opioid intake"  OR  “opioid related disorder"  OR  “morphine depend*"  OR  “morphine abuse*"  OR  “heroin depend*"  OR  “heroin abuse*"  OR  “opioid depend*"  OR  “opiate depend*"  OR  “opium depend*"  OR  “opioid misuse*"  OR  “narcotic use"  OR  “methadone use"  OR  “buprenorphine use"  OR  “opioid addic*” )	79,586
#3	#1 AND #2	6,656
#4	(TITLE-ABS-KEY (“systematic review”))	476,352
#5	#3 AND #4	272
	Limited to systematic review, humans, English [lang]; no date limits	249

PROSPERO/International prospective register of systematic reviews (NIHR): June 10, 2023

Search	Query	Records retrieved
#1	“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”	4,873
#2	“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”	751
#3	#1 AND #2	126
	Limited to completed [status]	4

ProQuest Dissertations & Theses A&I (ProQuest): June 10, 2023

Search	Query	Records retrieved
#1	abstract(“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain” )	4,038
#2	abstract(“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*” )	2,739
#3	#1 AND #2	143
#4	abstract(“systematic reviews”)	1,309
#5	#3 AND #4	0
	Limited to English [lang]; no date limits	0

Epistemonikos (https://www.epistemonikos.org): June 10, 2023

Search	Query	Records retrieved
#1	(title: (“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”) OR abstract: (“pain management” OR “analgesia” OR “perioperative pain” OR “postoperative pain” OR “post-surgery pain” OR “preoperative pain” OR “pre-surgery pain” OR “after surgery pain” OR “after operation pain” OR “before surgery pain” OR “before operation pain” OR “during surgery pain” OR “during operation pain” OR “post-operative pain” OR “pre-operative pain”))	32,785
#2	(title: (“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”) OR abstract: (“opioid user*” OR “opiate user*” OR “drug user*” OR “drug abuser” OR “OUD” OR " opioid use disorder” OR “LTOT” OR “long term opioid therapy” OR “opioid tolera*” OR “chronic opioid use” OR “preoperative opioid intake” OR “opioid related disorder” OR “morphine depend*” OR “morphine abuse*” OR “heroin depend*” OR “heroin abuse*” OR “opioid depend*” OR “opiate depend*” OR “opium depend*” OR “opioid misuse*” OR “narcotic use” OR “methadone use” OR “buprenorphine use” OR “opioid addic*”))	476
#3	#1 AND #2	332
	Limited to systematic review; no date limits	84

Appendix 2

List of AMSTAR2 questions

Q1. Did the research questions and inclusion criteria for the review include the components of PICO?

Q2. Did the report of the review contain an explicit statement that the review methods were established prior to the conduct of the review and did the report justify any significant deviations from the protocol?

Q3. Did the review authors explain their selection of the study designs for inclusion in the review?

Q4. Did the review authors use a comprehensive literature search strategy?

Q5. Did the review authors perform study selection in duplicate?

Q6. Did the review authors perform data extraction in duplicate?

Q7. Did the review authors provide a list of excluded studies and justify the exclusions?

Q8. Did the review authors describe the included studies in adequate detail?

Q9. Did the review authors use a satisfactory technique for assessing the risk of bias (RoB) in individual studies that were included in the review?

Q10. Did the review authors report on the sources of funding for the studies included in the review?

Q11. If meta-analysis was performed did the review authors use appropriate methods for statistical combination of results?

Q12. If meta-analysis was performed, did the review authors assess the potential impact of RoB in individual studies on the results of the meta-analysis or other evidence synthesis?

Q13. Did the review authors account for RoB in individual studies when interpreting/ discussing the results of the review?

Q14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review?

Q15. If they performed quantitative synthesis did the review authors carry out an adequate investigation of publication bias (small study bias) and discuss its likely impact on the results of the review?

Q16. Did the review authors report any potential sources of conflict of interest, including any funding they received for conducting the review?

Appendix 3

List of excluded reports in the full-text screening

Reason	Citation
Wrong study design: narrative review	Ward EN, Quaye AN, Wilens TE. Opioid Use Disorders: Perioperative Management of a Special Population. Anesth Analg. 2018 Aug;127(2):539–547. doi: https://doi.org/10.1213/ANE.0000000000003477. PMID: 29,847,389; PMCID: PMC6523021.
	Brooks MR, Golianu B. Perioperative management in children with chronic pain. Paediatr Anaesth. 2016 Aug;26(8):794–806. doi: https://doi.org/10.1111/pan.12948. PMID: 27,370,517.
	Hadi I, Morley-Forster PK, Dain S, Horrill K, Moulin DE. Brief review: perioperative management of the patient with chronic non-cancer pain. Can J Anaesth. 2006 Dec;53(12):1190-9. doi: https://doi.org/10.1007/BF03021580. PMID: 17,142,653.
	Prabhu M, Bortoletto P, Bateman BT. Perioperative pain management strategies among women having reproductive surgeries. Fertil Steril. 2017 Aug;108(2):200–206. doi: https://doi.org/10.1016/j.fertnstert.2017.06.010. Epub 2017 Jul 8. PMID: 28,697,915; PMCID: PMC5545053.
	Coluzzi F, Bifulco F, Cuomo A, Dauri M, Leonardi C, Melotti RM, Natoli S, Romualdi P, Savoia G, Corcione A. The challenge of perioperative pain management in opioid-tolerant patients. Ther Clin Risk Manag. 2017 Sep 5;13:1163–1173. doi: https://doi.org/10.2147/TCRM.S141332. PMID: 28,919,771; PMCID: PMC5592950.
	Lembke A, Ottestad E, Schmiesing C. Patients Maintained on Buprenorphine for Opioid Use Disorder Should Continue Buprenorphine Through the Perioperative Period. Pain Med. 2019 Mar 1;20(3):425–428. doi: https://doi.org/10.1093/pm/pny019. PMID: 29,452,378; PMCID: PMC6387981.
	Safley RR, Swietlikowski J. Pain Management in the Opioid-Dependent Pregnant Woman. J Perinat Neonatal Nurs. 2017 Apr/Jun;31(2):118–125. doi: https://doi.org/10.1097/JPN.0000000000000244. PMID: 28,437,302.
No perioperative pain management	De Aquino JP, Parida S, Avila-Quintero VJ, Flores J, Compton P, Hickey T, Gómez O, Sofuoglu M. Opioid-induced analgesia among persons with opioid use disorder receiving methadone or buprenorphine: A systematic review of experimental pain studies. Drug Alcohol Depend. 2021 Nov 1;228:109097. doi: https://doi.org/10.1016/j.drugalcdep.2021.109097. Epub 2021 Sep 22. PMID: 34,601,272; PMCID: PMC8595687.
	De Aquino, JP, Flores, JM, Avila-Quintero, VJ, Compton, P, Sofuoglu, M. Pharmacological treatment of pain among persons with opioid addiction: A systematic review and meta-analysis with implications for drug development. Addiction Biology. 2021; 26:e12964. https://doi.org/10.1111/adb.12964
	Taveros MC, Chuang EJ. Pain management strategies for patients on methadone maintenance therapy: a systematic review of the literature. BMJ Support Palliat Care. 2017 Dec;7(4):383–389. doi: https://doi.org/10.1136/bmjspcare-2016-001126. Epub 2016 Aug 26. PMID: 27,566,722.
Wrong population	Gallucci A, Lucena PH, Martens G, Thibaut A, Fregni F. Transcranial direct current stimulation to prevent and treat surgery-induced opioid dependence: a systematic review. Pain Manag. 2019 Jan 1;9(1):93–106. doi: https://doi.org/10.2217/pmt-2018-0053. Epub 2018 Dec 5. PMID: 30,516,441.