Inappropriate pain management after surgery is a major cause of the opioid crisis

Inappropriate pain management after surgery is a major cause of the opioid crisis

Publication date: Apr 12, 2019

Credit: CC0 Public Domain Targets to eliminate pain after surgery have driven increases in the use of opioids, and are a major cause of the opioid crisis in the USA, Canada and other countries.

“Providing opioids for surgical patients presents a particularly challenging problem requiring clinicians to balance managing acute pain, and minimising the risks of persistent opioid use after surgery,” says Series lead Professor Paul Myles, Monash University, Australia.

To reduce the increased risk of opioid misuse for surgery patients, we call for a comprehensive approach to reduce opioid prescriptions, increase use of alternative medications, reduce leftover opioids in the home, and educate patients and clinicians about the risks and benefits of opioids. “

In the USA, opioid prescribing for minor surgery has increased (up to 75% of patients are prescribed opioids at hospital discharge), and the risk of misuse increases by 44% for every week and for repeat prescription after discharge.

A US study of more than 155,000 patients having one of four low-risk surgeries (carpal tunnel repair, knee arthroscopy, keyhole surgery for gallbladder removal, or keyhole surgery for inguinal hernia repair) found that opioid prescriptions for each increased from 2004-2012, and that the average daily dose of opioid prescribed for post-surgical pain also increased by 13% (30 milligrams of morphine equivalent [MME]) across all procedures on average, with increases ranging from 8% (17 MMEs) for patients undergoing inguinal hernia repair to 18% (45 MMEs) for patients undergoing knee arthroscopy (see Figure in paper 2).

As well as often being ineffective at treating chronic pain, opioid prescriptions for pain after surgery have been linked to prescription opioid misuse and diversion, the development of opioid use disorder, and opioid overdose.

Storing excess opioid pills in the home is an important source of diversion, and in one study 61% of surgery patients had surplus medication with 91% keeping leftover pills at home.

Reducing opioid risks and improving management of chronic post-surgical pain The authors call for a comprehensive approach to reduce these risks, including specialist transitional pain clinics, opioid disposal options for patients (such as secure medication disposal boxes and drug take-back events) to help reduce home-stored opioids and the risk of diversion, and options for non-opioid and opioid-sparing pain relief.

To counter this, in the USA, a study devised prescribing recommendations for various surgeries (based on patient surveys and prescription refills data) – recommending postoperative opioids for 4-9 days for general surgery procedures, 4-13 days for women’s health procedures, and 6-15 days for musculoskeletal procedures.

We also need large population-based studies to help better understand the link between opioid use during surgery and chronic pain, and we need to understand what predisposes some people to opioid misuse so that we can provide alternative pain relief during surgery for these patients.

Concepts Keywords
Arthroscopy Surgeries
Australia Opioids
Biopsychosocial Pain
Canada Perception
Carpal Tunnel RTT
CC0 Euphoriants
Chronic Pain Morphinans
Dundee Pain management
Dutch Hyperalgesia
Epidemic Heroin
Fair Dealing Morphine
Gallbladder Keyhole surgery
General Anaesthetic General surgery
General Surgery Minor surgery
Healthcare Pain management surgery
Hip Fracture Acute chronic pain
Hospital Inguinal hernia
Hyperalgesia Hyperalgesia
Inadequate Healthcare
Inguinal Hernia
Keyhole Surgery
Lancet
Monash University
Morphine
Musculoskeletal
Netherlands
Neurobiological
Opioid
Opioid Overdose
Opioids
Overdose
Pain
Pain Management
Prescribed Medications
Tablets

Semantics

Type Source Name
drug DRUGBANK Tropicamide
gene UNIPROT LARGE1
gene UNIPROT ANP32B
gene UNIPROT TNFSF13
gene UNIPROT NR4A3
gene UNIPROT BEST1
gene UNIPROT CHL1
gene UNIPROT EHD1
gene UNIPROT RNF31
drug DRUGBANK Isoxaflutole
disease MESH hyperalgesia
gene UNIPROT SLC35G1
disease MESH chronic pain
disease MESH development
disease MESH satisfaction
gene UNIPROT ST13
gene UNIPROT RPL29
gene UNIPROT HHIP
gene UNIPROT REG3A
gene UNIPROT MMP12
gene UNIPROT MME
drug DRUGBANK Morphine
disease DOID inguinal hernia
disease MESH inguinal hernia

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