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.
- Temporal trends in opioid prescribing for common general surgical procedures in the opioid crisis era.
- Opioid Use: Study Finds Drop In Prescriptions
- To address the opioid crisis we need to do more to support people suffering from opioid use disorder
- Anxiety sensitivity and opioid misuse among opioid-using adults with chronic pain.
- Factors Associated With Patients’ Perceived Importance of Opioid Prescribing Policies in an Orthopedic Hand Surgery Practice.
- Despite Drug Abuse Crisis, Opioid Prescriptions Vary Widely From State to State: Study
- Sources and Main Motivations for Prescription Opioid Misuse Among Reproductive-Aged Parenting Women in the United States.
- Evaluating Chronic Pain Self-Management Support With an Opioid De-prescribing Intervention
- Health Literacy, Opioid Misuse, and Pain Experience Among Adults with Chronic Pain.
- Pediatric postoperative opioid prescribing and the opioid crisis.
- Opioid Treatment and Recovery Through a Safe Pain Management Program
- Study to research effectiveness of opioids versus medicinal marijuana in managing pain