Is there a problem with opioids and surgery?

In this step, Dr Fausto Morell-Ducos, Consultant in Anaesthesia and Pain Medicine at University College London Hospitals, outlines how the use of opioids in pain management around the time of surgery can lead to harm to patients and the wider community, and why there is a need for coordinated action to promote safer use of these drugs.

The need for perioperative opioid stewardship

Opioids are used in the treatment of moderate to severe pain after surgery. Put simply, they are drugs that work by binding to specialised opioid receptors, leading to a reduction in the transmission of pain signals in the central nervous system.

This very interaction, however, also triggers a complex cascade of intracellular signalling events which leads to dopamine release in parts of the brain similar to that associated with feelings of pleasure in activities such as eating or sex [1]. This burst of dopamine in the reward circuitry means that some people who use opioids can feel motivated to use them for reasons other than analgesia, developing opioid use disorder (OUD).

Over the past 30 years, increasing opioid prescribing in the United States and Canada has led to an increase in the illicit use of pharmaceutical and street opioids which has been associated with alarming rates of opioid-related morbidity and mortality, widely termed the Opioid Crisis or Opioid Epidemic. Although this crisis has been most well documented in North America, as you will see later in the course, there is evidence that it has parallels in many other countries in the world.

Aggressive marketing by pharmaceutical companies and over-prescription by physicians certainly seem to have played an important role in the development of this crisis, as recently portrayed in popular media productions such as Netflix’s 2023 explainer drama Painkiller or Patrick Radden Keefe’s 2021 bestseller Empire of Pain. The persistence and growth of this crisis over the last three decades, however, calls for self-reflection by prescribers and systemic coordination and improvement in order to achieve sustainable solutions. 

There is another aspect of this crisis which is less well publicised. Whilst 18% of the world’s population receive 93% of the world’s opioids, approximately 66% of the global population, mostly in low- and middle-income countries (LMIC), have almost zero access to these drugs. In India, for example, 95% of patients with advanced cancer are suffering with substantial pain but only 6% have access to strong opioids, whilst in the West some countries consume more than 3000% of their predicted need for opioids [2].

The reasons for under-prescribing and lack of access to opioids in LMICs include fear of causing dependence, addiction and diversion, as well as the lack of availability and affordability of these medicines. However, in trying to improve appropriate access to opioids where they are needed, it is important that lessons are learnt from the development of the Opioid Crisis in those affected countries.

Many of the factors which led to the development of the crisis in North America, and to a lesser extent Europe and Australia, were related to the prescription of opioids in chronic non-cancer pain. This is pain that lasts longer than three months and which is often associated with a disorder in pain processing in the central nervous system. There is now a substantial body of evidence which shows that opioids are not effective long-term medications in these patients.  We will touch briefly on why this is and how failure to appreciate this crucial difference between acute and chronic pain contributed to the development of the Opioid Crisis later in this week.

Opioids do, however, remain an important and effective component of perioperative acute pain management.  Could the use of opioids around the time of surgery also be contributing to the overall opioid epidemic?

Over the next three weeks of this course you will:

• explore the evidence linking the use of opioids in the perioperative period to these unwanted outcomes, as well as what you can do in your day-to-day practice to mitigate these risks
• discover how improving prescribing practices within hospitals and in the community is crucial, and you will hear from experts about their experiences in implementing these changes
• examine the importance of patient education about what to expect around the time of surgery, proper medication storage and disposal, and non-pharmacological pain-management strategies
• discuss the importance of following patients up after surgery in order to identify and support those who are struggling to stop opioids, as well as the specific interventions which can be deployed to achieve this goal
• evaluate the evidence for the use of strategies such as opioid-sparing and opioid-free anaesthesia and analgesia, as well as the constraints which limit their wider implementation. 

In the next step, you will look at two case studies which illustrate the harms that can be caused by poor management of prescribed opioids around the time of surgery.

References

_{1. Compton WM, Jones CM, Baldwin GT. Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. NEJM 2016;374:154-163.}

_{2. Knaul FM, Farmer PE, Krakauer EL, De Lima L, Bhadelia A, Jiang Kwete X, et al. Alleviating the access abyss in palliative care and pain relief—an imperative of Universal Health Coverage: The Lancet Commission Report. The Lancet. 2018;391(10128):1391-454.]}