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Perioperative opioids and the opioid epidemic

Has the use of opioids after surgery contributed to the opioid epidemic in the USA? In this article, Dr Jamie Smart discusses the evidence it has.
Female patient pouring pills from a cup on to hand at hospital
© UCL

In this step, Dr Jamie Smart, Consultant in Anaesthesia and Pain Medicine and Chair of the Opioid Stewardship Committee at University College London Hospitals, discusses how perioperative opioid use has contributed to the opioid epidemic in the United States.

Most of the factors we have described so far which contributed to the opioid crisis relate to the management of chronic non-cancer pain, and increasing awareness of these has led to significant changes in practice in that setting: opioids are no longer routinely recommended in the management of persistent pain [1].

Opioids, however, remain an important and most often necessary part of the delivery of effective perioperative analgesia. Could the use of opioids around the time of surgery have also contributed to the opioid crisis in the US? There is substantial evidence that this is the case.
The prescription of excessive doses or unnecessarily prolonged courses of opioids after surgery can lead to previously opioid-naïve patients continuing to take opioids long-term. According to one recent systematic review from the US, the incidence of persistent postoperative opioid use (PPOU) in opioid-naïve patients after surgery ranges between 0.6% to 26% in opioid-naïve patients, depending on the definition of PPOU used and the surgical population observed [2]. The incidence of persistent increased opioid use in those patients already exposed to opioids pre-operatively was even higher, from 35% to 77%. Although the estimates differ widely between the studies included, given the number of surgical procedures which take place every year, even the more conservative estimates would be a cause for concern.
Several factors have been found to be associated with this outcome, and PPOU estimates differ in other regions. We will look at these in greater detail later in Step 1.19 and throughout the course.
There is also evidence that the prescription of opioids around the time of surgery has contributed to the wider opioid epidemic indirectly, through the creation of a community reservoir of unused opioids which can be accessed by persons with opioid use disorder (OUD) for whom they were not intended.
According to one study from the US, healthcare professionals prescribe between two and ten times the dosage of opioids required by patients at discharge from hospital [3]. Of these excess drugs, between 50-90% were not disposed of. Another US study found that 26% of respondents reported saving pills prescribed for postoperative pain relief after they were no longer needed, although this number dropped to 12% among those who received information regarding appropriate disposal [4]. This community reservoir can therefore serve as a significant source for individuals with OUD, with up to two-thirds reporting obtaining opioids from friends and relatives.
There is growing concern regarding the role played by the use of opioids around the time of surgery in contributing to the increasing prevalence of both prescription and illicit opioid use in many settings. As a result, a number of interventions have been recommended which aim to minimise the risk of harm resulting from their use.

Such coordinated approaches, which aim to improve, monitor, and evaluate the use of opioids, have been termed opioid stewardship. They have gained credibility and support from several national and international societies, as well as demonstrating early promise in reducing chronic opioid use after surgery [5]. We will outline the individual domains and interventions which comprise opioid stewardship later this week, as well as discussing them in greater detail in Week 3.

A note on terminology:

Through the course we will refer to the following terms, so it may be helpful to look at the definitions below:

  • Opioid misuse: use of prescribed opioids in a way other than as directed by a healthcare professional.
  • Opioid abuse: intentional opioid use (prescribed or illegal) for a purpose other than pain relief (eg for relaxation or ‘getting high’).
  • Opioid diversion: transfer of a prescribed opioid medication to someone for whom it was not originally intended.
  • Opioid use disorder: a medical condition caused by a problematic pattern of opioid use (prescribed or illegal) causing impairment or distress. This can feature tolerance (when taking the same dose of a drug has diminishing effects over time), dependence (when stopping the drug causes withdrawal symptoms), and addiction (a severe form of OUD with continued use in spite of negative consequences to the individual and their loved ones).

References

1. Opioids Aware. Opioids for long term pain. Faculty of Pain Medicine 2023 [Accessed 15 January 2023].

2. Kent ML, Hurley RW, Oderda GM, Gordon DB, Sun E, Mythen M, et al. American Society for Enhanced Recovery and Perioperative Quality initiative-4 joint consensus statement on persistent postoperative opioid use: Definition, incidence, risk factors, and health care system initiatives. Anesthesia & Analgesia. 2019;129(2):543–52.

3. Hill MV, Mcmahon ML, Stucke RS, Barth RJ. Wide variation and excessive dosage of opioid prescriptions for common general surgical procedures. Ann Surg 2017;265:709-14.

4. Hero JO, McMurty C, Benson J, Blendon R. Discussing Opioid Risks With Patients to Reduce Misuse and Abuse: Evidence From 2 Surveys. Ann Fam Med 2016;14:575-577.

5. Macintyre PE, Quinlan J, Levy N, Lobo DN. Current Issues in the Use of Opioids for the Management of Postoperative Pain: A Review. JAMA Surg 2022;157:158-66.

© UCL
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Opioids and Surgery

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