Prolonged Opioid Use and Pain Outcome and Associated Factors after Surgery under General Anesthesia: A Prospective Cohort Association Multicenter Study

Abstract

Introduction There is insufficient prospective evidence regarding the relationship between surgical experience and prolonged opioid use and pain. We investigated the association of patient characteristics, surgical procedure, and perioperative anesthetic course with postoperative opioid consumption and pain three months post surgery. We hypothesized patient characteristics and intraoperative factors predict opioid consumption and pain three months post surgery. Methods Eleven U.S. and one European institution enrolled patients scheduled for spine, open thoracic, knee, hip, or abdominal surgery, or mastectomy in this multicenter, prospective observational study. Preoperative and postoperative data was collected using patient surveys and electronic medical records. Intra-operative data were collected from the Multicenter Perioperative Outcomes Group database. The association between postoperative opioid consumption and surgical site pain at three months, elicited from a telephone survey conducted at three months postoperatively, and demographics, psycho-social scores, pain scores, pain management, and case characteristics, was analyzed. Results Between September and October 2017, 3,505 surgical procedures met inclusion criteria. 1,093 cases were included; 413 patients were lost to follow-up, leaving 680 (64%) for outcome analysis. Preoperatively, 135 (20%) patients were taking opioids. Three months post surgery, 96 (14%) patients were taking opioids, including 23 patients (4%) who had not taken opioids preoperatively. 177 patients (27%) reported surgical site pain, including 45 (13%) patients who had not reported pain preoperatively. The adjusted odds ratio for 3-month opioid use was 18.6 (Credible Interval 10.3- 34.5) for patients who had taken opioids preoperatively. The adjusted odds ratio for three-month surgical site pain was 2.58 (1.45-4.4), 4.1 (1.73-8.9), and 2.75 (1.39-5.0) for patients who had site pain preoperatively, knee replacement, or spine surgery, respectively. Conclusions Preoperative opioid use was the strongest predictor of opioid use three months post surgery. None of the other variables showed clinically significant association with opioid use at three months after surgery.

The impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: a multi-specialty, prospective cohort study in 25 countries

“…22, 28 As noted by previous studies, patients using opioids preoperatively may be particularly vulnerable to uncontrolled pain and have a requirement for ongoing postoperative opioids. 29 Our study reinforces previous findings that opioid prescription on discharge is not independently associated with reduced pain severity, and indicates that clinicians should not prescribe opioids as a panacea for postoperative pain.…”

“…Given many patients undergoing arthroplasty are regular users of opioids in the pre-operative period, patients in this situation are at a higher risk of uncontrolled postoperative pain and chronic opioid use after surgery. 29 However, regardless of procedure, a multimodal approach to pain management is required, with preoperative assessment for high-risk pain characteristics, appropriate modulation of patient expectations, ongoing pain assessment, multimodal analgesia, non-pharmacological techniques, and pain treatment planning on discharge. 36 Preoperative counselling on pain management and opioid use may reduce patient reported pain scores, increase the likelihood of patients using non-pharmacological therapies, and increase levels of function at 6 months postoperatively.…”

Socioeconomic Characteristics Associated With Development of Chronic Pain After Pain Interference Experienced in Early Adulthood

“…These predictors of the new-onset pain were similar to results from cohort studies of stroke patients and patients experiencing neuropathic pain 33,34 . However, a study of the postsurgical pain found that neither patient demographics nor medical complexity (inferred from the American Society of Anesthesiologists physical status classification) were associated with the presence of pain at 3 months after surgery 35 . This null finding illustrates how, despite a general consensus that worse health is associated with the risk of future pain onset, results from prior studies are often conflicting with one another due to different populations and measures used.…”

“…33,34 However, a study of the postsurgical pain found that neither patient demographics nor medical complexity (inferred from the American Society of Anesthesiologists physical status classification) were associated with the presence of pain at 3 months after surgery. 35 This null finding illustrates how, despite a general consensus that worse health is associated with the risk of future pain onset, results from prior studies are often conflicting with one another due to different populations and measures used. By contrast, our analysis more directly demonstrated the similarities and differences in predictors of new-onset pain as compared with persistent pain within the same longitudinal survey.…”

Uncoupling Pain and Opioid Use after Surgery

“…In this issue of Anesthesiology , Kuck et al 3 prospectively investigated rates and predictors of prolonged postoperative surgical site pain as well as opioid use at 3 months in a cohort of patients undergoing a mix of surgical procedures. As in previous studies, 4 they found that preoperative opioid use was the strongest predictor of prolonged opioid use, with only about 4% of patients being “new” prolonged opioid users at 3 months.…”