Current Issues in the Use of Opioids for the Management of Postoperative Pain

Abstract

ncontrolled and indiscriminate prescribing of opioids during the past 3 decades has led to an opioid crisis that started in North America and spread throughout high-income countries. [1][2][3][4][5] This crisis initially drew attention to inappropriate prescribing of opioids for the management of chronic noncancer pain. 3 This is pain that persists for more than 3 months, is not associated with tissue damage but rather a dysfunctional pain system, and for which opioids are not recommended. 5,6 In contrast, opioids remain an effective and important component of the management of acute postoperative pain, although it has recently become clear that excessive or prolonged prescribing of opioids for postoperative pain relief, both in hospital and after discharge, may also be playing a role in the crisis and increasing patient harms. 5 The genesis of this crisis is exemplified by the title of a 2018 article, "Good Intentions Gone Bad, an Industry Gone Rogue, and Watch Dogs Gone to Sleep." 2 The aim of this narrative review was to explore some of the current issues surrounding the use of opioids in the perioperative period, including the drivers that led to escalation of use; the resultant in-crease in patient harms, including opioid-induced ventilatory impairment (OIVI); the move away from using self-reported pain scores alone to assess adequacy of analgesia or to guide titration of opioids; concerns about the routine use of long-acting opioids including controlledrelease (also known as slow-, extended-, modified-, or sustainedrelease) formulations for the management of acute pain; and concerns about prescription of opioids on discharge from hospital. In addition, therehasbeenincreasingrecognitionthatpreadmissionlong-termopioid use can affect both short-term and long-term postoperative outcomes. Finally, this review addresses whether opioid-free anesthesia and analgesia (OFAA) might have a role to play in reducing postoperative opioid-related harms. MethodsWe searched the PubMed, Web of Science, Google Scholar, and Cochrane Library databases on June 8, 2021, using the terms opioid cri-IMPORTANCE Uncontrolled and indiscriminate prescribing of opioids has led to an opioid crisis that started in North America and spread throughout high-income countries. The aim of this narrative review was to explore some of the current issues surrounding the use of opioids in the perioperative period, focusing on drivers that led to escalation of use, patient harms, the move away from using self-reported pain scores alone to assess adequacy of analgesia, concerns about the routine use of controlled-release opioids for the management of acute pain, opioid-free anesthesia and analgesia, and prescription of opioids on discharge from hospital.OBSERVATIONS The origins of the opioid crisis are multifactorial and may include good intentions to keep patients pain free in the postoperative period. Assessment of patient function may be better than unidimensional numerical pain scores to help guide postoperative analgesia. Immediate-release opi...

Reply by Authors

“…We totally agree with the comments that a combination of measures with a multilayered approach, rather than a single best intervention, are required to positively impact the opioid prescribing behavior. 2,3 The reduction in opioid prescriptions realized by various interventions is encouraging, but is it enough? A statistically significant reduction in prescribed opioid tablets can still result in excessive prescribing, as evident from the unused, leftover opioids reported in the post-intervention cohorts.…”

“…We totally agree with the comments that a combination of measures with a multilayered approach, rather than a single best intervention, are required to positively impact the opioid prescribing behavior. 2,3…”

Species-specific cutaneous protein signatures upon incision injury and correlation with distinct pain-related phenotypes in humans

“…Due to insufficient knowledge about the multifaceted processes leading to acute and chronic pain after surgery, the current therapeutic options are sparse. For severe post-surgical pain, opioids and regional anesthesia techniques are most effective, but both are limited by side effects, risks, and long-term consequences (9). Pure systemic non-opioid analgesic regimens are therefore affordable, but most available drugs are of low efficacy and associated with significant adverse events and therefore not recommended for the treatment of post-surgical pain (10,11).…”

The need to improve opioid prescribing and data collection in patients undergoing orthopaedic surgery

“…This can be partially attributed to `big pharma´promoting the use of the World Health Organization (WHO) analgesic ladder for cancer pain for the management of types of pain that historically would be managed by simple analgesics and non-pharmacological strategies [1]. Despite the belief initially purported by the drug companies that prescribed opioids are safe, they are actually dangerous and cause death and harm by overdose and other adverse effects [2][3][4]. It is now well recognised that the global opioid crisis that started in the USA in the 1990s and directly contributed to over 100,000 deaths worldwide in 2017, originated with the aggressive marketing and subsequent misuse of prescription opioids [2,3].…”

“…Despite the belief initially purported by the drug companies that prescribed opioids are safe, they are actually dangerous and cause death and harm by overdose and other adverse effects [2][3][4]. It is now well recognised that the global opioid crisis that started in the USA in the 1990s and directly contributed to over 100,000 deaths worldwide in 2017, originated with the aggressive marketing and subsequent misuse of prescription opioids [2,3]. The economic and societal effects of the opioid crisis on the USA economy are staggering, with an estimated 450,000 opioid-related deaths over the past two decades, and an annual financial cost to the economy of $700 billion to $1 trillion, which equates to 3.4% of the USA gross domestic product [2].…”