The intersection of harm reduction and postoperative care for an illicit fentanyl consumer after major surgery: A case report

Abstract

Background: As Canada continues to address challenges related to the opioid crisis, individuals suffering from opioid use disorder (OUD) can be especially vulnerable to physical and psychological destabilization after surgery. Adopting a harm reduction approach postoperatively can be a success factor for safe recovery and satisfactory analgesia. Purpose: We present the case of a 40-year-old patient (referred to as DC) with OUD using illicit fentanyl, heroin, and oxycodone preoperatively and admitted for an elective liver resection for steroid-induced hepatoma. Despite a preoperative anesthesia assessment and the initiation of a standard balanced multimodal analgesic regimen, suboptimal analgesia was evident in the first 24 h postoperatively. This lack of analgesic efficacy precipitated DC’s use of illicit self-injected intravenous (IV) opioid and significant emotional distress. To address this, a nurse practitioner and anesthesiologist within the Toronto General Hospital acute and transitional pain program and the surgical team quickly met and adopted a harm reduction approach to manage DC’s postoperative pain and emotional distress. The ultimate goal was to eliminate self-administration of illicit IV opioids and prevent DC from attempting to leave hospital against medical advice. Following an interprofessional team discussion that included DC, IV fentanyl was offered via a patient-controlled analgesia pump to DC’s satisfaction (exceeding standard settings), providing acceptable pain relief. To our knowledge, DC did not self-administer additional illicit drugs during the remainder of hospitalization. Outcome: This harm reduction approach resulted in DC’s safe recovery, achievement of postoperative functional milestones, and continued engagement with outpatient pain treatment.