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Rates and risk factors for prolonged opioid use after major surgery: population based cohort study

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1251 (Published 11 February 2014) Cite this as: BMJ 2014;348:g1251

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Re: Rates and risk factors for prolonged opioid use after major surgery: population based cohort study

Sir,
The recent paper by Clarke et al., brings to light a problem faced by pain specialists in managing post-operative pain.[1] However, there are certain concerns which we would like to highlight.

1.The cohort studied by them was above the age of 65. This age group is highly susceptible to chronic pain and vulnerable to various drug interactions, not to mention side effects of the drugs.[2] Therefore, there is a strong need to recommend non-pharmacological interventions among this age group in order to reduce the side effects of opioids and other pharmacological agents in this group of patients.

2.Clarke et al., identified various key risk factors towards prolonged opioid use (viz., persistent postsurgical pain). Thus, it may be safe to say that these high risk groups (e.g., post thoracotomy patients, adjusted OR: 2.58) also receive non-pharmacological interventions as an adjunct to pharmacological interventions during the post-operative period. Studies have shown transcutaneous electrical nerve stimulation (TENS) to be a useful adjunct to pharmacological interventions.[3] A recent trial found reduction in narcotic consumption to 7.8mg of morphine among those receiving TENS as an adjunct to pharmacotherapy as compared to 12.3 mg in the control group.[4] This was also accompanied by a greater reduction in pain scores among those receiving TENS from 6 – 120 hours post-operatively.

3. There is lack of clarity regarding adjunctive therapy (both pharmacological and non-pharmacological) utilized in this cohort – thus adding to potential confounders. Current clinical practice utilises non-opioid pharmacological agents and regional analgesia along with opioids.[5] Administration of opioids as a sole agent, will therefore pose a great challenge to pain specialists with regard to risk of long term use.

Thus, in order to minimize the risk of prolonged use along with minimizing the side effects of opioids, there is a strong rationale for using non-pharmacological agents like TENS during the acute management of pain in post-operative patients. Better high quality research is required in this area so as to help contribute to future meta-analysis and evidence based recommendations.

References:
1. Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014 Feb 11;348:g1251
2. Abdulla A, Adams N, Bone M, Elliott AM, Gaffin J, Jones D, Knaggs R, Martin D, Sampson L, Schofield P; British Geriatric Society. Guidance on the management of pain in older people. Age Ageing. 2013 Mar;42 Suppl 1:i1-57
3. Freynet A, Falcoz PE. Is transcutaneous electrical nerve stimulation effective in relieving postoperative pain after thoracotomy? Interact Cardiovasc Thorac Surg. 2010;10:283-8
4. Fiorelli A, Morgillo F, Milione R, Pace MC, Passavanti MB, Laperuta P, Aurilio C, Santini M. Control of post-thoracotomy pain by transcutaneous electrical nerve stimulation: effect on serum cytokine levels, visual analogue scale, pulmonary function and medication. Eur J Cardiothorac Surg. 2012;41:861-8
5. Gandhi K, Baratta JL, Heitz JW, Schwenk ES, Vaghari B, Viscusi ER. Acute pain management in the postanesthesia care unit. Anesthesiol Clin. 2012;30:e1-15

Competing interests: No competing interests

03 March 2014
Abraham Samuel Babu
Physical therapist
Nisha Sara M Jacob, DA*, Henry Prakash, MD**
Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal - 576104, Karnataka, India
*Department of Anesthesia, Christian Medical College, Vellore - 632004, Tamil Nadu, India, **Department of Physical Medicine & Rehabilitation, Christian Medical College, Vellore - 632004, Tamil Nadu, India