Controlled-release opioids cause harm and should be avoided in management of postoperative pain in opioid naïve patients

Impact of modified-release opioid use on clinical outcomes following total hip and knee arthroplasty: a propensity score-matched cohort study

Modified-release opioids are often prescribed for the management of moderate to severe acute pain following total hip and knee arthroplasty, despite recommendations against their use due to increasing concerns regarding harm. The primary objective of this multicentre study was to examine the impact of modified-release opioid use on the incidence of opioid-related adverse events compared with immediate-release opioid use, among adult inpatients following total hip or knee arthroplasty. Data for total hip and knee arthroplasty inpatients receiving an opioid analgesic for postoperative analgesia during hospitalisation were collected from electronic medical records of three tertiary metropolitan hospitals in Australia. The primary outcome was the incidence of opioid-related adverse events during hospital admission. Patients who received modified with or without immediate-release opioids were matched to those receiving immediate-release opioids only (1:1) using nearest neighbour propensity score matching with patient and clinical characteristics as covariates. This included total opioid dose received. In the matched cohorts, patients given modified-release opioids (n = 347) experienced a higher incidence of opioid-related adverse events overall, compared with those given immediate-release opioids only (20.5%, 71/347 vs. 12.7%, 44/347; difference in proportions 7.8% [95%CI 2.3-13.3%]). Modified-release opioid use was associated with an increased risk of harm when used for acute pain during hospitalisation after total hip or knee arthroplasty.

Risks and benefits of oral modified-release compared with oral immediate-release opioid use after surgery: a systematic review and meta-analysis

Prescription of modified-release opioids for acute postoperative pain is widespread despite evidence to show their use may be associated with an increased risk of adverse effects. This systematic review and meta-analysis aimed to examine the available evidence on the safety and efficacy of modified-release, compared with immediate-release, oral opioids for postoperative pain in adults. We searched five electronic databases from 1 January 2003 to 1 January 2023. Published randomised clinical trials and observational studies on adults who underwent surgery which compared those who received oral modified-release opioids postoperatively with those receiving oral immediate-release opioids were included. Two reviewers independently extracted data on the primary outcomes of safety (incidence of adverse events) and efficacy (pain intensity, analgesic and opioid use, and physical function) and secondary outcomes (length of hospital stay, hospital readmission, psychological function, costs, and quality of life) up to 12 months postoperatively. Of the eight articles included, five were randomised clinical trials and three were observational studies. The overall quality of evidence was low. Modified-release opioid use was associated with a higher incidence of adverse events (n = 645, odds ratio (95%CI) 2.76 (1.52-5.04)) and worse pain (n = 550, standardised mean difference (95%CI) 0.2 (0.04-0.37)) compared with immediate-release opioid use following surgery. Our narrative synthesis concluded that modified-release opioids showed no superiority over immediate-release opioids for analgesic consumption, length of hospital stay, hospital readmissions or physical function after surgery. One study showed that modified-release opioid use is associated with higher rates of persistent postoperative opioid use compared with immediate-release opioid use. None of the included studies reported on psychological function, costs or quality of life.

Factors related to opioid misuse among patients undergoing elective surgery in Poland

In many countries, the consumption of illicit opioids is rising, becoming a major public health issue called the "opioid crisis". Many reasons contribute to this phenomenon. One of them is opioid misuse, defined as the use of legally prescribed opioids for a purpose different than pain treatment. This matter has not been well studied in Poland, where the opioid crisis has not been identified so far. This study was conducted among patients admitted for elective surgery with opioid-based postoperative pain treatment. The frequency of opioid misuse was found to be 10.8% in a sample comprising 92 patients. The group of individuals with potential opioid use disorder had a more frequent history of inadequately controlled postoperative pain compared to the group of non-misusers (p = 0.023). Furthermore, this group asked to receive additional pain treatment almost six times more often than the control group (p < 0.000). Also, patients declaring opioid misuse reported substantial differences concerning their knowledge and opinions about pain treatment and opioid analgesics: supporting the administration of opioids for pain when needed, finding opioids less harmful, and supporting messages that opioids are safe, effective, well-tolerated, easy to cutoff more often than control. There is an urgent need for the education of patients to avoid the spreading of the opioid crisis.

Bones, groans and sending patients home: Perioperative opioid-related harm reduction strategy utilisation in a regional New South Wales (NSW) hospital

OBJECTIVE

Perioperative initiation of opioids continues to be a major contributor to chronic use, misuse and diversion in regional areas. There is considerable effort to mitigate harm through avoiding excessive prescribing and reducing the risk of persistent postoperative opioid use. Improving perioperative documentation practices has been reported to ensure appropriate opioid initiation and de-escalation. It has not been established whether these strategies are utilised in regional hospitals.

METHODS

A retrospective observational study of perioperative opioid prescribing and documentation practices in Goulburn Base Hospital, a regional centre in the Southern New South Wales (NSW) Local Health District. Data were collected from 110 records and validated for adult patients undergoing elective total knee replacement (TKR) or total hip replacement (THR) from 12 January 2020 to 13 January 2021.

OUTCOME MEASURES

To observe perioperative opioid prescribing and utilisation of harm reduction strategies in a regional hospital.

RESULTS

65% of patients were opioid naïve (ON). Preoperative pain assessments and patient education were completed in 23% and 15% of records, respectively. Postoperative opioids were prescribed for 99% of patients, with 74% prescribed a slow-release (SR) formulation. 50% of patients were discharged with an SR prescription. Inadequate postoperative pain control was reported in 21% of patients. Of the 103 patients prescribed opioids on discharge, only 20% included a de-escalation plan and only 35% of discharge summaries included dose and quantity of opioids supplies.

CONCLUSIONS

This study has identified underutilisation of perioperative harm reduction strategies despite the potential to improve appropriate initiation and de-escalation of opioids. These findings highlight opportunities for improvement in regional hospitals.

No place for routine use of modified-release opioids in postoperative pain management

Modified-release opioid tablets were introduced into surgical practice in the belief that they provided superior pain relief and reduced nursing workload, and they rapidly became embedded into many perioperative pathways. Although national and international guidelines for the management of postoperative pain now advise against the use of modified-release opioids, they continue to be prescribed in many centres. Recognition that modified-release opioids show lack of benefit and increased risk of harm compared with immediate-release opioids in the acute, postoperative setting has become clear. Their slow onset and offset make rapid and safe titration of these opioids impossible, including down-titration as the patient recovers; pain relief may be less effective; they have been associated with an increased incidence of opioid-related adverse drug events, increased length of hospital stay, and higher readmission rates; and they lead to higher rates of opioid-induced ventilatory impairment and persistent postoperative opioid use. Evidence indicates that modified-release opioids should not be used routinely in the postoperative period.

How to close the gaps between evidence and practice for perioperative opioids

Excellent resources are now available that distil the best evidence around opioid prescribing in the perioperative period, including the list of recommendations provided by the international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. While some of the recommendations have been widely accepted as an essential part of postoperative practice, others have had slow and variable adoption. This article focuses on the items where theory and practice still diverge and suggests how best to close that gap. We must also remain mindful that while education is essential, it is on the lowest rung of implementation efficacy and, on its own, is a poor driver of behaviour change. Ongoing structural nudges and the use of local procedure-specific analgesic pathways will also be helpful in addressing the gap between evidence-based recommendations and practice.

Current Issues in the Use of Opioids for the Management of Postoperative Pain: A Review

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 opioids can be titrated more easily to match analgesic requirements. There is currently no good evidence to show that opioid-free anesthesia and analgesia affects opioid prescribing practices or the risk of persistent postoperative opioid use. Attention should be paid to discharge opioid prescribing as repeat and refill prescriptions are risk-factors for persistent postoperative opioid use. Opioid stewardship is paramount, and many governments are passing legislation, while statutory bodies and professional societies are providing advice and guidance to help mitigate the harm caused by opioids.

Conclusions and Relevance

Opioids remain a crucial part of many patients' journey from surgery to full recovery. The last few decades have shown that unfettered opioid use puts patients and societies at risk, so caution is needed to mitigate those dangers. Opioid stewardship provides a multilayered structure to allow continued safe use of opioids as part of broad pain management strategies for those patients who benefit from them most.

Opioid prescription at postoperative discharge: a retrospective observational cohort study

Opioid misuse is now considered a major public health epidemic in North America, with substantial social and financial consequences. As well as socio-economic and commercial drivers, modifiable risk-factors that have resulted in this crisis have been identified. The purpose of this study was to identify whether, within England, modifiable drivers for persistent postoperative opioid use were present. This was a retrospective cohort study of practice at 14 National Health Service hospitals across England. Data were collected retrospectively and validated for adult patients undergoing elective intermediate and major or complex major general surgical procedures between 1 and 31 March 2019. Of the 509 patients enrolled from 14 centres, 499 were included in the data analysis. In total, 31.5% (157/499) patients were in the intermediate surgery cohort and 68.5% (342/499) were in the major or complex major surgery cohort, with 21.0% (33/157) and 21.6% (74/342) discharged with opioid medicines to be taken at regular intervals, respectively. There were similar median oral morphine equivalent doses prescribed at discharge. Of patients prescribed regular opioid medicines, 76.6% (82/107) had a specified duration at discharge. However, 72.9% (78/107) had no written deprescribing advice on discharge. Similarly, of patients prescribed 'when required' opioids, 59.6% (93/156) had a specified duration of their prescription and 33.3% (52/156) were given written deprescribing advice. This study has identified a pattern of poor prescribing practices, a lack of guidance and formal training at individual institutions and highlights opportunities for improvement in opioid-prescribing practices within England.

Surgery and opioids: evidence-based expert consensus guidelines on the perioperative use of opioids in the United Kingdom

There are significant concerns regarding prescription and misuse of prescription opioids in the perioperative period. The Faculty of Pain Medicine at the Royal College of Anaesthetists have produced this evidence-based expert consensus guideline on surgery and opioids along with the Royal College of Surgery, Royal College of Psychiatry, Royal College of Nursing, and the British Pain Society. This expert consensus practice advisory reproduces the Faculty of Pain Medicine guidance. Perioperative stewardship of opioids starts with judicious opioid prescribing in primary and secondary care. Before surgery, it is important to assess risk factors for continued opioid use after surgery and identify those with chronic pain before surgery, some of whom may be taking opioids. A multidisciplinary perioperative care plan that includes a prehabilitation strategy and intraoperative and postoperative care needs to be formulated. This may need the input of a pain specialist. Emphasis is placed on optimum management of pain pre-, intra-, and postoperatively. The use of immediate-release opioids is preferred in the immediate postoperative period. Attention to ensuring a smooth care transition and communication from secondary to primary care for those taking opioids is highlighted. For opioid-naive patients (patients not taking opioids before surgery), no more than 7 days of opioid prescription is recommended. Persistent use of opioid needs a medical evaluation and exclusion of chronic post-surgical pain. The lack of grading of the evidence of each individual recommendation remains a major weakness of this guidance; however, evidence supporting each recommendation has been rigorously reviewed by experts in perioperative pain management.

An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients

This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.

Multimodal oral analgesia strategy after ambulatory arthroscopic shoulder surgery: case series using adaptive therapeutic approaches by sequential analysis

BACKGROUND

Pain control and quality of recovery (QoR) at home remains a challenge after ambulatory shoulder arthroscopy. This study aims to assess the QoR and pain relief using a sequential implementation strategy for rescue analgesic drugs.

METHODS

After institutional review board approval, patients (>18 years, American Society of Anesthesiology [ASA] score 1-3 stable) scheduled for ambulatory surgery under general anesthesia with a single-shot interscalene nerve block were enrolled. After discharge, patients received standard information regarding the postoperative recovery and care consisting of a multimodal analgesic regime (acetaminophen and ketoprofen for 5 days). The first 48 postoperative hours allowed us to compare 3 different rescue drug regimes with a control group, in sequential order: tramadol (control group), tramadol + nefopam, immediate-release oxycodone (IR), and extended-release oxycodone (ER). The primary endpoint was the QoR 40 score at 48 hours after surgery. Secondary endpoints were pain relief and adverse events over a 7-day period. An intention-to-treat statistical analysis was performed with sequential analysis (as an interim analysis) every 20 patients. Results were recorded as medians and interquartiles (25-75).

RESULTS

We analyzed 109 patients with similar characteristics among groups. The QoR 40 scores were similar for the tramadol group (168 [161-172]), the tramadol + nefopam group (161 [151-173], P = .09), and the IR group (164 [153-169], P = .17), but higher for the ER group (176 [167-181], P = .03). Concerning adverse events, drugs were interrupted more frequently in the tramadol + nefopam group (36 %). In the ER group, a higher quality of postoperative relief was attained in the domains of pain and sleep.

CONCLUSION

The present study shows that a combination of IR and ER oxycodone over a short period of time (<48 hours) is associated with a better QoR at home after ambulatory shoulder surgery.

Perioperative opioid use and misuse

Prescribed opioid misuse in North America is a public health crisis, with huge social, medical and economic repercussions. Surgery is an identified driver for persistent opioid use and misuse. The UK has also seen a surge in opioid consumption per capita and it is now necessary for primary and secondary care to work together to mitigate the problem of perioperative prescribed opioid misuse.This review discusses the identified drivers for persistent opioid use following surgery and discusses the remedial actions that must be taken by all stakeholders to mitigate the UK developing its own perioperative prescribed opioid crisis.