Preoperative opioid use is reported in 23.1 percent of patients undergoing surgery. However, there is an increased incidence of patients who receive prescription opioids after surgery compared with nonsurgical patients.
In fact, a study of health insurance claims showed that patients undergoing two of the most common types of surgery were at an increased risk of becoming chronic users of opioid painkillers.
Although prescriptions for opioids are most often related to surgical care, recent data suggest that 6 percent of patients undergoing either major or minor elective surgical procedures develop long-term opioid dependence. In 2015, U.S. drug overdose deaths exceeded 50,000; 30,000 involved opioids.
Surgeons have been targeted as contributing to the nation's opioid epidemic by overprescribing opioids for post-operative pain relief. Both the doctors dealing with patients perioperatively and the surgical patients themselves therefore face the important clinical challenge of how best to adequately manage acute postoperative pain while tackling patients’ understandable concerns about developing long-term opioid use.
Although opioids are critical in addressing certain types of pain, such as acute and cancer-related pain, some suggest that the best way to deal with potential opioid dependence after surgery is to skip surgery altogether. However, there are other less radical options to help surgical patients taper off opioids safely and successfully.
A new study reinforces the need for surgeons and physicians to monitor patients' use of painkillers following surgery by using alternative methods of pain control whenever possible.
The study followed 251 high-risk patients at Toronto General Hospital (TG), University Health Network who were dichotomized preoperatively as opioid-naïve or opioid-experienced. Outcomes included pain, opioid consumption, weaning rates, and psychosocial/medical comorbidities.
To help post-surgical patients with their pain levels and to taper opioid use, or wean to zero if possible, patients in the study were referred to the Transitional Pain Program. This program included a phone call within 72 hours after surgery and follow-up meetings twice a month initially, and then monthly from three to six months.
The program endeavors to help and teach patients to manage their pain, including prescribing non-opioid medications and using psychological techniques such as mindfulness and exercise/acupuncture by a team of pain specialists — physicians, nurses, psychologists, and physiotherapists.
Six months after surgery, pain and function were significantly improved. Opioid-naïve and opioid-experienced patients reduced consumption by 69 percent and 44 percent, respectively. Forty-six (46) percent and 26 percent weaned completely.
Consumption at hospital discharge predicted weaning in opioid-naïve patients. Pain catastrophizing, neuropathy, and recreational drug use predicted weaning in opioid-experienced patients.
One of the strongest predictors of remaining on opioids long-term, after hospital discharge is the dose on discharge — the higher the dose, the more likely a patient will remain on opioids long-term.
According to Dr. Hance Clarke, director of the Transitional Pain Service at TG and the medical director of the Pain Research Unit at TG, identifying at-risk patients, such as those who had pre-existing pain, mental health issues, and chronic use of opioids before surgery, is critical in developing follow-up plans and educating patients and other healthcare clinicians. Dr. Clarke also touts the program as a good blueprint not only for surgical patients but for anyone else dealing with an opioid addiction.
