Clinical and Economic Burden of Opioid Use for Postsurgical Pain: Focus on Ventilatory Impairment and Ileus

Abstract

Opioid-related adverse drug events (ORADEs) can have a significant impact on patient recovery after surgery. This review investigates the impact of two ORADEs, respiratory depression and postoperative ileus (POI), on clinical and economic outcomes. Opioid-induced ventilatory impairment is a potentially serious ORADE that can result in apnea and even death. The incidence of ventilatory impairment is approximately 1%, even among patients receiving opioids using patient-controlled analgesia. Costs are increased in patients treated with opioids who are at high risk of ventilatory impairment due to the need for more intensive monitoring from nursing staff and the use of alarmed monitoring equipment. Opioids, together with other factors, contribute to the development of POI through a direct effect on gut motility. Postoperative ileus has been shown to significantly increase hospital length of stay and cost of care. A key determinant of ileus development, as well as length of stay and costs, is postsurgical opioid dose. Data from a retrospective analysis show that a daily hydromorphone dose of 2 mg/day markedly increases the risk of POI. In addition, although the incidence of POI is reduced in patients who undergo laparoscopic surgery or hand-assisted laparoscopic surgery compared with open surgery, the reduction of POI can potentially be negated by excessive opioid use. Therefore, multimodal, opioid-sparing strategies should be explored and used to reduce severe ORADEs and improve outcomes in the surgical setting.

Avoiding Adverse Events Secondary to Opioid-Induced Respiratory Depression

“…[10][11][12][13][14][15] Nursing assessments of sedation levels during opioid administration are recommended by both evidence-based practice guidelines [14][15][16][17][18] and TJC. 8 Some contend that this parameter should be the 6th vital sign.…”

“…12 In nonsurgical populations, the incidence of opioid-attributed adverse events is estimated at 0.6%. 13 There are several reasons for the increase in pain managementYrelated adverse events. One of the main reasons is the advent of more aggressive pain management strategies.…”

Fentanyl effects on breath generation in C57BL/6J and A/J mouse strains

“…Adverse events related to opioid use, primarily opioid-induced respiratory depression, are potentially fatal complications in both adult and pediatric populations (Barletta, 2012; Boom et al, 2012; Golder et al, 2013; Jarzyna et al, 2011; Jungquist et al, 2011; Niesters et al, 2013; Panagiotou and Mystakidou, 2012; Whittaker, 2013). Respiratory side effects are increased in those with pre-existing cardiovascular and respiratory conditions and with normal circadian dips in ventilation (Mortola, 2004; Mortola and Seifert, 2002).…”

Instituting Best Practice for Monitoring for Opioid‐Induced Advancing Sedation in Hospitalized Patients

“…With greater focus on complying with mandated pain assessments and efforts to improve patient satisfaction with pain care, it is vitally important that opioid administration be balanced with safe analgesic administration practices. The science for safe opioid use has expanded, with stronger evidence to guide opioid prescribing and patient monitoring practices for acute pain and to identify patients at risk for opioid‐related adverse events (Ashburn et al., ; Barletta, ; Jarzyna et al., ; Jungquist, Karan, & Perlis, ; MacIntyre et al., ; Rathmell et al., ; Taylor, Kirton, Staff, & Kozol, ). To ensure that hospital leaders and clinicians respond appropriately to reduce opioid‐related adverse events, The Joint Commission (TJC) is proposing relevant quality measures (Joint Commission, ).…”

“…Of these events, root causes were found to be 47% wrong‐dose medication errors, 29% related to improper monitoring, and 11% related to other factors, such as excessive dosing and medication interactions (Joint Commission, ). A recent report estimates the risk of respiratory impairment with Patient Controlled Analgesia (PCA) at 1% (Barletta, ). Concerns about opioid‐induced respiratory depression in hospital settings prompted TJC to release a Sentinel Event Alert (Joint Commission, ).…”