Opioid vs Opioid-Free Analgesia After Surgical Discharge

Key Points

Opioid prescribing at surgical discharge for minor and moderate surgeries does not reduce pain intensity; however, it does increase adverse events. In the accompanying editorial¹ the authors noted, "opioids after discharge should be reserved only for people recovering from major surgery, and this prescription should incorporate an opioid-tapering strategy."

Relevance

Although opioid prescribing patterns have begun to change, opioids continue to be routinely prescribed for even minor surgeries where their benefit-to-harm ratio may place patients at risk of increased adverse effects

Comments

The results of this recent analysis by a multidisciplinary team including members of the Department of Surgery at McGill University remind me of similar eye-opening results of the SPACE trial from the VA in 2018, which demonstrated that opioid analgesics did not have significant benefits beyond well-planned nonopioid pain care while also increasing adverse effects.

In this case, we have similar findings that challenge long-standing prescription patterns which typically dictate that discharge–no matter the type of surgery–require some type of opiate prescription.

The unfortunate departure from previous chronic pain management trials comes on the journey home from surgery. While we have an increasing number and comfort with recommending interventions such as those noted in the American College of Physicians guidelines, the toolbox home from surgery is much emptier. Even when there is research evidence, there is much less availability and comfort in knowing how to fully support our patients going home, especially with nonpharmacological, behavioral, and physical therapies in the already fragile post-op scenario.

However, this review shows us that in some ways we are making that fragile scenario even more problematic by providing an opioid prescription in more cases than not. Hopefully, it will draw more attention to efforts such as that by Stanford’s Dr. Beth Darnall whose My Surgical Success is using presurgical behavioral care to reduce post-op pain, anxiety, and medication requirement.² Certainly, this approach needs to be individualized especially for patients who are on chronic opioids and for many others. This study will hopefully initiate expansive clinical trials of what a practical and accessible nonopioid discharge toolbox should look like so that patients and care teams can carefully begin to have practical options that will help translate this research into clinical practice.

Details

In total, 47 trials (N = 6607 participants), which examined prescriptions after minor surgeries (predominately dental and hand surgery) and moderate surgeries (eg, minimally invasive orthopedic or general surgery), were included. This study did not look at major surgeries (ie, bowel, liver, and lung resections).

• Compared with opioid-free analgesia, use of post-procedure opioids did not yield improved pain either on day 1 after discharge (moderate certainty) or on other days (low to moderate certainty) but,
• Did carry higher risks for:
• GI side effects (vomiting, nausea, constipation)
• Central side effects (dizziness, drowsiness).
• Limitations included heterogeneity of the trials and procedures as well as focus on pain versus function.

References

1. Myles PS, Bui T. Opioid-Free Analgesia After Surgery. Lancet. 2022;399(10343):2245-2247. https://doi.org/10.1016/s0140-6736(22)00777-2
2. Ziadni MS, You DS, Keanne R, et al. “My Surgical Success”: Feasibility and Impact of a Single-Session Digital Behavioral Pain Medicine Intervention on Pain Intensity, Pain Catastrophizing, and Time to Opioid Cessation After Orthopedic Trauma Surgery – A Randomized Trial. Anesth Analg. 2022 Jun 13. doi: 10.1213/ANE.0000000000006088. Online ahead of print. https://doi.org/10.1213/ane.0000000000006088