A single dose of pre‐operative pregabalin reduces post‐operative opioid use after orthotopic liver transplantation

Abstract

The opioid epidemic remains a critical public health crisis with an estimated 46 802 overdose deaths in the United States in 2018, accounting for 69.5% of all drug overdose deaths. 1 Furthermore, the economic impact of prescription opioid-related overdose, abuse, and dependence is estimated to exceed 78.5 billion dollars annually. 2 A rising clinical dilemma facing healthcare providers in the midst of the opioid crisis has been the appropriate use of opioids for post-surgical pain management. Despite the known risks of opioids, opioid monotherapy remains a core element of peri-operative pain management.Even when intended for short-term use, research demonstrates that patients receiving opioid prescriptions within 7 days of surgery were 44% more likely to become long-term opioid users within 1 year compared with those without an opioid prescription. 3 Opioid minimization is of unique interest in liver transplantation, since opioid use after liver transplantation has been associated with worsened mortality and long-term graft survival. 4,5 The American Pain Society and American Society of Anesthesiologists evidenced-based guidelines endorse the use of a multimodal analgesic approach to peri-operative pain management in an effort to minimize opioid use. 6 Multimodal analgesia is a strategy that employs the use of opioid and non-opioid analgesics to target various pain pathways, maximize efficacy, and minimize medication-related complications. In a meta-analysis of 52 randomized control trials, multimodal analgesia in post-operative patients

A systematic review of opioid use and multimodal strategies in solid organ transplant recipients and living donors

“…Within this population, there were various assessments of nonopioid analgesic medications in the postoperative transplant setting. Eleven studies evaluated the impact of a single opioid‐sparing medication including pregabalin, continuous systemic lidocaine, and local anesthetics (single and continuous dosing) 18,37–46 . Furthermore, seven studies evaluated the impact of a multimodal analgesic strategies, and two assessed the impact of different education‐based interventions 19–21,47–52 …”

“…Efficacy outcomes were variable, but generally included evaluation of opioid use and PRPS. Each comparative study demonstrated a statistically significant reduction in opioid use for those who received the various minimization intervention(s) 18–21,37–42,47–52 . Patient‐reported pain scales were also evaluated, but the impact of opioid minimization interventions varied by study 19,37,41,42,50 .…”

“…Overall, 319 patients (167 patients in opioid minimization intervention arms) were analyzed in the included single‐center retrospective cohort studies ( n = 4). In the single study that evaluated one preoperative dose of pregabalin, MME requirements were lower through 72 h post‐transplant 38 . Within the multimodal pain management protocols, pre and postoperative gabapentin in combination with scheduled APAP, opioid‐sparing anesthetics, “as needed” tramadol, and ketamine were all incorporated with the intention of minimizing opioid use 19,51,52 .…”

“…Eleven studies evaluated the impact of a single opioid-sparing medication including pregabalin, continuous systemic lidocaine, and local anesthetics (single and continuous dosing). 18,[37][38][39][40][41][42][43][44][45][46] Furthermore, seven studies evaluated the impact of a multimodal analgesic strategies, and two assessed the impact of different education-based interventions. [19][20][21][47][48][49][50][51][52] Efficacy outcomes were variable, but generally included evaluation of opioid use and PRPS.…”

“…Each comparative study demonstrated a statistically significant reduction in opioid use for those who received the various minimization intervention(s). [18][19][20][21][37][38][39][40][41][42][47][48][49][50][51][52] Patient-reported pain scales were also evaluated, but the impact of opioid minimization interventions varied by study. 19,37,41,42,50 When evaluating LOS and opioid prescribing at discharge, the impact of opioid minimization strategies also conferred variable results across the included studies but were not worse than control group analgesic regimens.…”