A unique pain program is helping complex surgical patients wean off opioids safely and effectively while offering alternative ways to cope with their pain and improve how they function. A study following 251 surgical patients at risk of developing chronic pain or persistent opioid use.

They found that almost half of patients who did not take opioids before surgery were able to wean off opioids, and one in four of those who did take opioids before surgery were able to wean completely. The study was published in the Canadian Journal of Pain, "Opioid Weaning and Pain Management in Post-Surgical patients at the Toronto General Hospital Transitional Pain Service."

Prescription opioids play an important role in addressing certain kinds of pain they are the best pharmacological option available for acute pain and widely used for cancer-related pain. But the high overall rate of opioid prescribing in Canada has raised concerns, and prescribing in the context of non-cancer pain has been called into question. 

Pain After Surgery

The study followed patients at high-risk for developing chronic pain and problematic opioid use for six months after surgery. In patients who did not take opioids for a year before surgery, the study found that 69% were able to reduce their opioid consumption, with 45% of them being able to stop completely.

Opioid Prescription

Those patients who were taking a prescription opioid before surgery reduced their opioid use by 44%, with 26% of them weaning off completely. The assumption is that all patients after surgery are fine with their opioid use, but we have found that in a high-risk segment of patients, that is not the case.

They need better ways of identifying these patients and then helping those who are having difficulty in reducing or eliminating their opioid use. Otherwise, we run the risk of de-escalating patients too fast and having them look elsewhere for opioids or other drugs if we don't guide them.

Post-Surgical Pain

Follow-up for the surgical patients referred to the Transitional Pain Program in this study included a phone call within 72 hours after surgery and follow-up meetings twice a month initially, and then monthly from three to six months. The goal is to prevent acute pain from becoming a chronic post-surgical pain and taper opioid use or wean to zero if possible.

Distress Factors

For patients who were on opioids before surgery, emotional distress factors such as anxiety or depression, and pain catastrophizing excessive pain-related worry, along with an inability to deflect thoughts from pain were important factors in how well these patients could wean off opioids.

Identifying at-risk patients, typically those who have pre-existing pain, mental health issues, chronic use of opioids before surgery, is critical so that we can develop follow-up plans, and educate patients and other healthcare clinicians.

Our program is a good blueprint that they can use not only for surgical patients but anyone else dealing with opioid addiction. The report notes that starting a patient on a dose of opioids higher than 90 MEQ has been shown to increase the risk of death from opioid poisoning relative to starting on a low dose. 

Strategies

For a sub-population of patients who struggle with pain disability after surgery, it is important that we support them with appropriate pharmacological and non-pharmacological strategies.