Targets to eliminate pain after surgery have driven increases in the use of opioids, new research shows.
For the first time, a new Series of three papers*, published in The Lancet, brings together global evidence detailing the role of surgery in the opioids crisis.
Each year there are 320 million people having surgery, and chronic pain occurs in 10% of cases.
It typically begins as acute postoperative pain that is difficult to control, and develops into a persistent pain condition with features that are unresponsive to opioids. In response to this pain, clinicians often prescribe higher levels of opioids, but this can lead to tolerance and opioid-induced hyperalgesia, creating a cycle of increased pain and increased opioid use where pain remains poorly managed.
“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. “Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse, and overdose-related deaths. 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.”
The opioid crisis began in the US during the mid-1990s and early 2000s, state the authors, when inadequate pain relief was seen as a marker of poor-quality healthcare. Opioids are now one of the most commonly prescribed medications in the USA with similar, although less marked, trends in other high-income countries, including the UK.
“From the mid-1990s, clinical guidelines and policies were created that aimed to eliminate pain, and clinicians were encouraged to increase opioid prescriptions. As a result, the use of prescription opioids more than doubled between 2001-2013 worldwide – from three billion to 7.3 billion daily doses per year, and has been linked to increases in misuse and abuse in some countries – like the US, Canada, Australia and the UK,” says Series author Dr Brian Bateman, Brigham and Women’s Hospital, USA.
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.
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.
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.
“Ultimately, chronic pain after surgery requires a comprehensive biopsychosocial approach to treatment. Transitional pain clinics are a new approach at bridging the divide, aiming to eliminate overprescribing of opioids after surgery. These clinics could help identify those at risk of chronic pain after surgery, and offer additional clinic visits, review treatment, refer the patient to alternative services, such as rehabilitation, addiction medicine, mental health services, and chronic pain services. Together this could help to reduce opioid use and abuse,” says Professor Myles.
Clinical guidelines and policies must also provide consensus for prescribing opioids after surgery, offering clinicians default and maximum prescription levels, state the authors.
More research is also needed, they say, to help effectively manage opioid tolerance and opioid-induced hyperalgesia.
“Better understanding of the effects of opioids at neurobiological, clinical, and societal levels is required to improve future patient care,” says Series author Professor Lesley Colvin, University of Dundee, UK. “There are research gaps that must be addressed to improve the current opioid situation. Firstly, we must better understand opioid tolerance and opioid-induced hyperalgesia to develop pain relief treatments that work in these conditions. 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. These recommendations affect many areas of the opioid crisis and could benefit to the wider crisis too.”
*Series of three papers:
Glare P, Aubrey KR, Myles PA. Transition from acute to chronic pain after surgery. The Lancet. Published: April 13, 2019. DOI:10.1016/S0140-6736(19)30352-6
Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. The Lancet. Published: April 13, 2019. DOI:10.1016/S0140-6736(19)30428-3
Colvin LA, Bull F, Hales TG. Perioperative opioid analgesia—when is enough too much? A review of opioid-induced tolerance and hyperalgesia. The Lancet. April 13, 2019. DOI:doi.org/10.1016/S0140-6736(19)30430-1