ASRA Pain Medicine Update

How could an opioid health crisis of this magnitude occur in the United States of America?  The opioid epidemic has been described as “coming in waves,” with the first wave occurring in the late 90’s when self-reported pain became the fifth vital sign.¹ Providers were required to address pain control and, if this was done poorly, it would be considered practicing outside the standard of care and subject to diminished reimbursement.  At the same time, pharmaceutical corporations assured the medical community of the safety of prescription opioids.² Patient expectations shifted to the point where pain was no longer a logical side-effect of surgical procedures but instead represented a failure on the part of the medical community.  Television advertisements for opioid medications increased to the point that patients could request prescriptions by name for a variety of painful conditions and the result was an unprecedented number of prescriptions for opioid analgesics provided by well-intentioned physicians.  Concordantly, illegal street drugs garnered the majority of national attention while the increasing numbers of opioid overdose deaths remained underreported. With the second opioid epidemic wave in 2010, overdoses of opioid analgesics skyrocketed, but once again, were underreported because heroin deaths garnered more attention secondary to the associated risk/rise in the spread of infectious diseases HIV and Hepatitis C.  The third wave of the opioid epidemic presented in 2016, with increasing deaths related to the availability of highly potent synthetic opioids. In recognition of the deadly opioid problem, the Centers for Disease Control (CDC) published guidelines to facilitate safe opioid management in patients with chronic non-cancer pain, with an emphasis of prescribing “no greater quantity than needed.”³  The CDC acknowledged that opioid therapy for postsurgical pain was outside the scope of the guideline.  Best practice advisories for postsurgical pain published in the literature at that time focused on multimodal analgesia to reduce opioid consumption during the perioperative time.^4,5 However,  they failed to provide recommendations on post-discharge opioid management. It was not until recently that significant attention focused on opioid overdose rates and persistent use following surgery discharge.

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Despite the patient benefits that might be realized, postoperative opioid tapering remains an essential aspect of perioperative pain management that has been overlooked for years.

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Despite the opioid epidemic, these agents remain the mainstay of treatment for severe postsurgical pain. The time immediately following surgery represents a vulnerable period for patients as they may be exposed to opioids for the first time in an unsupervised home setting or require an escalation of their chronic opioid dose. In this setting, a strong correlation exists between the duration of postsurgical opioid use and the subsequent development of opioid misuse. In fact, each refill and additional week of opioid use is associated with a 44% adjusted increase in the rate of misuse.⁶

In addition to concerns regarding duration of use, there is currently a wide discordance between opioid prescribing and consumption in most postsurgical patients and the quantity prescribed is often significantly higher than patient-reported consumption.⁷ Every additional opioid pill prescribed was associated with 0.53 more pills consumed in a study conducted across 33 health systems in Michigan.⁸  In an attempt to satisfy the analgesic requirements and minimize overprescribing and persistent use, practice guidelines emerged that focused on opioid therapy after surgery discharge. The Agency Medical Director Group developed post-discharge guidelines that provided recommendations on the duration of opioid therapy based on expected time for recovery.⁹ The Michigan Surgical Quality Collaborative provided recommendations on the number of pills to be dispensed based on the type of opioid being prescribed for a specified procedure.¹⁰

In the past few years, there have been an increasing number of studies attempting to evaluate opioid overdose rates following surgical discharge. A study conducted by Ladha et al. examined the frequency of opioid overdose and how this outcome was related to preoperative opioid use calculated in morphine milligram equivalents (MMEs). The frequency of opioid overdose decreased with time, and more occurrences were found in the first 30 days following surgery discharge.  This study also found that opioid overdose increased with increasing amounts of preoperative opioid use.  Patients on > 100 MMEs/day prior to surgery had a higher rate of opioid overdose after surgery discharge.¹¹ In a similar study, an 11-fold increase in the frequency of opioid overdose occurred during post-discharge days 0-30 compared to days 31-365 in a study that monitored patients over a one-year time span after surgery.¹²

 Persistent use of opioids after surgery is an underappreciated surgical complication. Persistent opioid use has been described as continued opioid use 90-180 days after surgery.¹³ The incidence rate for persistent opioid use in opioid-naive patients undergoing minor surgery was  5.9% and after major surgery was 6.5%.¹³  The incidence rate for continued use of opioids 6 months after surgery in opioid-naïve patients undergoing total knee arthroplasty (TKA) was 8.2% and 4.3% for total hip arthroplasty (THA). The incidence rate for continued use of opioids at 6 months in non-opioid-naïve patients was 53% for TKA and 34.7% for THA.¹⁴ Patients undergoing open and minimally invasive thoracic procedures were associated with a higher risk of prolonged opioid use while open and minimally invasive major gynecological procedures were associated with a lower risk.¹⁵ 

Prolonged opioid use following surgery may not be simply a consequence of severe or poorly controlled pain. Pain after major surgery is certainly expected to be greater than pain after minor surgery.  However, a recent study by Brummet et al. demonstrated that there was no difference in the incidence for chronic opioid use after minor or major surgery in opioid-naïve patients.¹³   If chronic opioid requirements following surgery are not related to surgical pain, then are they due to patient-level predictors? Patients undergoing surgery are clearly at risk for postsurgical pain. It is a subjective experience that is modulated by many factors that include psychological, behavioral, and medical characteristics. These individual factors may render some patients susceptible to heightened acute postoperative pain which can lead to an increased risk for chronic opioid use after surgery. Preoperative use of benzodiazepines and antidepressants along with history of depression, preexisting pain disorder, alcohol, and drug abuse was associated with an increased risk of chronic opioid use after surgery.^13,16

There is a huge knowledge gap regarding optimal tapering strategies for pre- and postoperative opioids. How much and how frequently do we wean? We need randomized trials evaluating perioperative opioid tapering to support opioid prescribing policies. Approximately 12.5% of patients present to surgery with a history of preoperative opioid consumption and are generally discharged with prescriptions that represent a 100%–300% increase over baseline preoperative opioid doses.¹⁷  Unfortunately, this is frequently done without a clear plan to cease opioid requirements or wean the dose of opioid back to baseline levels.

Despite the generally increased awareness of an opioid use epidemic, prescribers have continued to provide opioids after surgery and have trended toward increasing morphine equivalents.¹⁸

Opioid weaning guidance in the perioperative period is, unfortunately, limited and is generally contained in expert opinion located clinical guidelines. Despite the patient benefits that might be realized, postoperative opioid tapering remains an essential aspect of perioperative pain management that has been overlooked for years. There needs to be an increased recognition among surgeons, anesthesiologists, and patients that an important component of minimizing opioid use after surgery is ensuring that a proper opioid tapering strategy is carefully considered and employed at the time of discharge.

The perioperative period provides a critical window to address opioid use, particularly in patients with a history of chronic pain. Interdisciplinary teams consisting of a variety of healthcare professionals need to focus on individualizing pain management plans with a framework for nonpharmacological and pharmacological pain management, opioid weaning, and psychosocial/psychological interventions that help patients during this vulnerable time.¹⁹

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Dalia H. Elmofty, MD, is an associate professor and associate program director of the Pain Fellowship at the University of Chicago.

References:

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4. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-73.
5. Chou R, Gordon DB, de Leon-Casasola OA, et al. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-57.
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