Author: Bob Kronemyer
Nearly one in four patients is given opioids immediately before surgical intervention, according to a large cross-sectional, observational study at a tertiary care academic medical center.
The study, which appears in JAMA Surgery, collected information from 34,186 patients, with a mean age of 53.1 years, from March 2010 through April 2016 (JAMA Surg 2018 Jul 11. [Epub ahead of print]).
Overall, 23.1% of patients reported preoperative opioid use.
For several years, principal investigator Paul Hilliard, MD, was the director of regional anesthesiology and acute pain medicine at Michigan Medicine at the University of Michigan, in Ann Arbor, where it was not uncommon for him to encounter patients who had surgery and were already physiologically tolerant to opioids.
“This made it very challenging to care for these patients after surgery,” Dr. Hilliard said. “Also, increasing the opioids was very dangerous in this population.”
Dr. Hilliard wanted to help identify those patients before surgery and determine whether there was anything that could be done to optimize recovery. “These patients are medically more complex and have things in common that put them at higher risk for adverse events after surgery,” he said. “They are also more likely to have psychological comorbidities.”
The study concluded that preoperative opioid use was most prevalent in patients undergoing orthopedic (65.1%) and neurosurgical spinal (55.1%) procedures, as opposed to thoracic (15.7%) and cardiac (10.8%) procedures.
“Despite this variance, I was struck by the sheer number of patients presenting for surgery with opioid use,” Dr. Hilliard said. “This is potentially a modifiable risk factor. And if you consider opioid use a medical issue, then it is the most common medical issue for surgical patients.”
Dr. Hilliard said while many efforts and even legislation currently focus on limiting post-op prescribing, little has been accomplished to identify opioid patients before surgery and establish best practices for opioid dispensing to achieve surgical optimization.
However, Dr. Hilliard acknowledged that not all patients can reduce their pre-op opioid use. “It really depends on the dose and duration of use,” he said. “But opioid use should certainly prompt a conversation with the surgical team and inform decisions around preoperative pain control.”
If the opportunity to reduce opioid use exists, such as for an elective surgery that is scheduled at least weeks in advance, reduction in opioids should be contemplated in anticipation of postsurgical pain, according to Dr. Hilliard. “This is really something that needs to be looked at on a case-by-case basis,” he said. “However, I would caution providers that not all patients can or are appropriate for dose reduction. But at a minimum, it gives providers and patients an opportunity to develop an individualized and safe pain management plan.”
Naloxone rescue strategies at patient discharge should be deliberated for all patients new to opioids with an existing medical condition, such as cardiovascular or pulmonary comorbidities. “These strategies should also be considered in patients using higher doses of opioids or anytime an opioid is coprescribed with a benzodiazepine,” Dr. Hilliard said.
It is important to educate the patient’s family and friends about naloxone rescue, for which implementation will be variable, depending on the medical system. “Using the patient’s electronic medical record with ‘logic’ to identify patients at risk can be considered and, perhaps more importantly, patient education about the dangers associated with opioid use,” Dr. Hilliard said.
For postoperative opioid prescribing, Dr. Hilliard believes an emphasis should be placed on nonsteroidal anti-inflammatory drugs and acetaminophen. “These should be first line for pain control,” he said. “Local anesthetics, membrane stabilizers and some muscle relaxers can also be useful. Overall, a multimodal approach to pain control and shifting the paradigm away from opioids is critical. Opioids should be the last resort, not the first thing used for postoperative pain. Both providers and patients need to start thinking of opioids as the adjunct.”
Besides developing some rational patient and provider education, “considering strategies to reduce opioids in anticipation of surgery is the next step,” Dr. Hilliard said.
Heath McAnally, MD, MSPH, the medical director at Northern Anesthesia and Pain Medicine LLC, in Eagle River, Alaska, is not surprised by the study results. “These prevalence data fall into line with those reported previously,” he said. In addition, “the risk factor constellation—not just opioids—identified in the paper may serve as a surrogate for decreased self-efficacy, which may also predispose to self-selection for elective surgery. For instance, it is not surprising to see higher opioid and tobacco rates in surgical patients compared to the general population.”
Dr. McAnally believes the incidence of preoperative opioid use needs to be reduced. “The literature is fairly convincing that preoperative opioid use is associated with a host of adverse consequences and poor surgical outcome,” said Dr. McAnally, who summarized much of this in a review last year in Perioperative Medicine (2017;6:19) and is currently co-writing a book addressing a handful of high-yield modifiable risk factors.
“I have learned, though, over the years that you cannot simply take opioids away from people,” Dr. McAnally said. “You have to replace them with a better alternative that addresses the underlying biopsychosocial–spiritual—not just somatic—distress that people are seeking comfort from. There is not a simple solution.”
The task requires considerable therapeutic rapport, motivational enhancement and a health promotion focus, according to Dr. McAnally. “If post-traumatic stress disorder, sleep deprivation, proinflammatory diet and sedentary lifestyle, among other factors, are contributing to the pain that ostensibly motivates opioid use, we will not get anywhere without fixing these issues concurrently,” he said.