Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol

Abstract

The practice of chronic opioid prescription for chronic non-cancer pain has come under considerable scrutiny within the past several years as mounting evidence reveals a generally unfavorable risk to benefit ratio and the nation reels from the grim mortality statistics associated with the opioid epidemic. Patients struggling with chronic pain tend to use opioids and also seek out operative intervention for their complaints, which combination may be leading to increased postoperative “acute-on-chronic” pain and fueling worsened chronic pain and opioid dependence.Besides worsened postoperative pain, a growing body of literature, reviewed herein, indicates that preoperative opioid use is associated with significantly worsened surgical outcomes, and severely increased financial drain on an already severely overburdened healthcare budget. Conversely, there is evidence that preoperative opioid reduction may result in substantial improvements in outcome. In the era of accountable care, efforts such as the Enhanced Recovery After Surgery (ERAS) protocol have been introduced in an attempt to standardize and facilitate evidence-based perioperative interventions to optimize surgical outcomes. We propose that addressing preoperative opioid reduction as part of a targeted optimization approach for chronic pain patients seeking surgery is not only logical but mandatory given the stakes involved. Simple opioid reduction/abstinence however is not likely to occur in the absence of provision of viable and palatable alternatives to managing pain, which will require a strong focus upon reducing pain catastrophization and bolstering self-efficacy and resilience.In response to a call from our surgical community toward that end, we have developed a simple and easy-to-implement outpatient preoperative optimization program focusing on gentle opioid weaning/elimination as well as a few other high-yield areas of intervention, requiring a minimum of resources.

Classifying Preoperative Opioid Use for Surgical Care

“…For example, in spine and joint replacement surgery where opioid use is prevalent, preoperative opioid reduction and referrals to pain specialists have improved clinical and patient-reported outcomes. [29][30][31] Future studies may help target preoperative optimization toward patients at highest opioid-related risk.…”

The Surgeon's Role in the Opioid Crisis: A Narrative Review and Call to Action

“…The third broad way that preoperative opioid use may be altered is through tapering or weaning patients from these medications prior to surgery (43). Unlike the first two strategies, this approach aims to respond to patients who have already been exposed to opioids, rather than preventing preoperative opioid initiation.…”

Associations between pre-surgical daily opioid use and short-term outcomes following knee or hip arthroplasty: a prospective, exploratory cohort study

“…Given the above concerns, opioid tapering is recommended for chronic opioid users prior to elective surgery [18,24], thus, tapering may be a useful strategy for chronic opioid users prior to arthroplasty. However, prior to recommending what is likely to be a resourceintensive, multi-pronged approach [24,25], evidence from prospective trials, controlling for important confounders, are needed to accurately depict both the extent of the problem and the associated harms.…”