Managing Prolonged Pain After Surgery: Examining the Role of Opioids

Abstract

A notable minority of patients experience persistent postsurgical pain and some of these patients consequently have prolonged exposure to opioids. Risk factors for prolonged opioid use after surgery include preoperative opioid use, anxiety, substance abuse, and alcohol abuse. The window to intervene and potentially prevent persistent opioid use after surgery is short and may best be accomplished by both surgeon and anesthesiologist working together. Anesthesiologists in particular are well positioned in the perioperative surgical home model to affect multiple aspects of the perioperative experience, including tailoring intraoperative medications and providing consultation for possible discharge analgesic regimens that can help minimize opioid use. Multimodal analgesia protocols reduce opioid consumption and thereby reduce exposure to opioids and theoretically the risk of persistent use. Regional anesthesia and analgesia techniques also reduce opioid consumption. Although many patients will recover without difficulty, the small minority who do not should receive customized care which may involve multiple office visits or consultation of a pain specialist. Enhanced recovery pathways are useful in optimizing outcomes after surgery.

Predictors of the use of analgesic drugs 1 year after joint replacement: a single-center analysis of 13,000 hip and knee replacements

“…Persistent pain may also lead to the increased consumption of analgesics [8]. To date, however, only a limited number of large-scale studies have been conducted on the trajectories of analgesic consumption and the risk factors associated with increased analgesic consumption after surgery [9][10][11][12][13][14][15][16][17][18][19][20][21], even though the risks for adverse events of opioids and non-steroidal anti-inflammatory drugs increase in long-term use [22][23][24], especially in elderly patients with comorbidities.…”

Letter to the Editor on “Opioid-Sparing Analgesia and Enhanced Recovery After Total Knee Arthroplasty Using Combined Triple Nerve Blocks With Local Infiltration Analgesia”

“…Although a 10 mg or 25-30% intravenous opioid difference is considered clinically significant in most studies on postoperative analgesia. However, most of those studies [2,3] were conducted to compare between a placebos or single intervention group with a multiple intervention group, contrary to our study which is an active comparison between multiple peripheral nerve blocks combined with multimodal analgesia. Therefore, the drastic differences in postoperative analgesia and opioid consumption, albeit statistically significant, were not observed between the groups.…”

Strategies to address the U.S. opioid crisis in the perioperative setting

“…An ideal postoperative analgesic regimen should incorporate specific medications to address all the components of pain (e.g., neuropathic, inflammatory). The physician should consider if opioids are even needed and, if so, the optimal prescription . A multimodal analgesic approach is often recommended and has been shown to reduce opioid consumption in surgical patients .…”

“…Non‐opioid medications, such as acetaminophen or ibuprofen, should first be encouraged for pain treatment, as should non‐ pharmacologic options, including ice, elevation, physical therapy, electrotherapy, and acupuncture . Peripheral nerve blocks and neuraxial analgesia are other options to reduce opioid use while still reaching recovery objectives . Prochazka indicated that assessing patient pain and respiratory status also is vital in the postoperative period.…”

“…The timeframe patients are initially prescribed opioids postoperatively significantly affects the chances they continue to take opioids for months or years . The Centers for Disease Control and Prevention recommends that opioids be prescribed for the shortest timeframe possible .…”