Inappropriately managed post-surgery pain that becomes chronic and long-lasting is a major contributor to the global opioid epidemic, according to a landmark series in The Lancet.
The three papers making up the Lancet series, from researchers in Australia, the United States and Scotland, document the role of inappropriate opioid prescribing after surgery as a major cause of the opioid epidemic.
The emerging opioid epidemic
In the USA, up to 75 percent of minor surgery patients are prescribed opioids at hospital discharge with no plan to monitor their use or to wean patients off painkillers. The study shows that the risk of misuse increases by 44 percent for every week and for repeat prescription after discharge.
Co-author of the first paper Professor Paul Glare from the University of Sydney and Director of the Pain Management Research Institute said the series brings together global evidence detailing the role of surgery in the opioid crisis.
"In the time since the Lancet last covered the topic of chronic pain after surgery, the world has seen the emergence of the opioid epidemic. Our article highlights some of the new options for pain management after surgery as we redefine the role of opioids for chronic pain."
Worldwide, use of prescription opioids more than doubled between 2001-2013, from 3 billion to 7.3 billion daily doses per year, and doctors in many countries give medication in excess of what is needed for pain control, increasing the risks of misuse or diversion.
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 but is particularly common after lung, hernia and breast surgery.
Breaking the cycle: increased pain, increased opioid use
Each year there are 320 million people having surgery around the world, including more than two million in Australia, and chronic pain occurs in 10 percent 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.
Over the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain.
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, Head of Monash University's Department of Anaesthesia and Perioperative Medicine.
"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 address the increased risk of opioid misuse for surgery patients the authors identify the following strategies:
- Specialised clinics for tapering patients off opioids after surgery
- Drug monitoring policies
- Improved medical training in opioid prescribing
- New pain management methods including the use of alternative pain relief medication.
Professor Glare and colleagues at the Pain Management Research Institute are exploring innovative ways to support better pain management and assist people to reduce or cease medication through services such as text messaging to support opioid de-prescribing.
They are also holding a workshop in Sydney later this year to teach general practitioners and other clinicans the skills needed to help patients wean off pain killers.
