General surgery

Targets to eliminate pain after surgery have driven increases in the use of opioids, and are a major cause of the opioid crisis in the USA, Canada and other countries. For the first time; a new Series of three papers, published in The Lancet, brings together global evidence detailing the role of surgery in the opioids crisis. Chronic post-surgical pain is a growing problem as the population ages and more surgeries are done. It can occur after any type of surgery.

Higher levels of opioids

Each year there are 320 million people having surgery, and chronic pain occurs in 10% of cases. It typically begins as acute postoperative pain that is difficult to control, and develops into a persistent pain condition with features that are unresponsive to opioids. In response to this pain; clinicians often prescribe higher levels of opioids, but this can lead to tolerance and opioid-induced hyperalgesia (a counterintuitive increase in pain in line with increased opioid consumption); creating a cycle of increased pain and increased opioid use where pain remains poorly managed.

“Providing opioids for surgical patients presents a particularly challenging problem requiring clinicians to balance managing acute pain; and minimising the risks of persistent opioid use after surgery;” says Series lead Professor Paul Myles, Monash University; Australia. “Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain; which has been associated with a rising epidemic of prescription opioid misuse, abuse, and overdose-related deaths.

To reduce the increased risk of opioid misuse for surgery patients; we call for a comprehensive approach to reduce opioid prescriptions; increase use of alternative medications, reduce leftover opioids in the home, and educate patients and clinicians about the risks and benefits of opioids.”

Opioid use after surgery

The opioid crisis began in the US during the mid-1990s and early 2000s; when inadequate pain relief is seen as a marker of poor quality healthcare. Opioids are now one of the most commonly prescribe medications in the USA with similar, although less marked, trends in other high-income countries; including the UK.

Comparatively, many low-income countries worldwide have little access to opioids and cannot provide appropriate pain relief as highlighted in The Lancet Commission on Global Access to Palliative Care and Pain Relief. Because “From the mid-1990s; clinical guidelines and policies are create that aimed to eliminate pain; and clinicians are encourage to increase opioid prescriptions.

Opioid administration

As a result, the use of prescription opioids more than doubled between 2001-2013 worldwide from 3 billion to 7.3 billion daily doses per year; therefore and has been linked to increases in misuse and abuse in some countries  like the US, Canada, Australia and the UK.” Says Series author Dr Brian Bateman; Brigham and Women’s Hospital; USA.
Currently, opioids are often the best pain relief available for managing acute pain. In surgery, opioid administration reduces the dose of general anaesthetic needed; and timely and appropriate opioids after surgery improve patient comfort. However, the persistent use of opioids after surgery can predispose patients to long-term opioid use and misuse so ongoing must be carefully considered. Because In the USA; opioid prescribing for minor surgery has increased (up to 75% of patients are prescribed opioids at hospital discharge); therefore  and the risk of misuse increases by 44% for every week and for repeat prescription after discharge.