Re: Rates and risk factors for prolonged opioid use after major surgery: population based cohort study
Dear Sir,
Clarke et al. are concerned that 3.1% of patients over 65 years of age were receiving prescribed opioids 180 days following major surgery [1]. Our concern is that that figure may be too low if effective pain management is to be achieved.
First, the prevalence of moderate-to-severe chronic post-surgical pain (CPSP) in patients is rarely below 5% in epidemiological studies [2, 3]. This may extend to over 10% in thoracic surgery, coronary bypass graft, and hysterectomy – which accounted for more than half the cohort in Clarke’s study [1-3]. Although CPSP may be due to neuropathic pain, and require specific management, it is not unreasonable to suppose that many might also benefit from opioid therapy. Indeed opioids have been recognized as having a role to play in CPSP [4, 5].
Secondly, it is not clear if some of the 3% were actually suffering pain following re-operation for procedures linked to their initial operation – so somatic pain management would be entirely appropriate.
Thirdly, many of these patients will have been prescribed opioids given the increasingly well-recognized renal, gastrointestinal and cardiovascular contra-indications to NSAIDS in this age group.
Fourthly, the study was unable to address what proportion of patients were actually using the prescribed analgesics “as required”, or for “rescue analgesia”, and in what dosage. (Clearly there is a concern that patients may transfer opioid stocks to other uses, but this is probably more likely in a younger population).
While we appreciate that the dose and duration of opioids used for postoperative pain should be limited and subject to regular review, consideration of the balance of benefits versus side effects will in many cases require opioids to be continued under supervision. “Normal” practice from a statistical point of view suggests that 2.5% of patients would continue to require opioid analgesia…..3.1% is not far off!
Naheed JIVRAJ
MBBS Candidate, King's College London
MSc. International Health Policy (LSE)
Dr Colm LANIGAN MB BCh BAO DCH MRCPI MD FRCA FPM(RCOA)
Consultant Anaesthetist, University Hospital Lewisham, Lewisham & Greenwich Healthcare NHS Trust, London SE13 6LH.
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;348:g1251 doi: 10.1136/bmj.g1251
2. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet;367(9522):1618-25 doi: 10.1016/S0140-6736(06)68700-X
3. Macrae WA. Chronic post-surgical pain: 10 years on. British Journal of Anaesthesia 2008;101(1):77-86 doi: 10.1093/bja/aen099
4. Jin F, Chung F. Multimodal analgesia for postoperative pain control. Journal of Clinical Anesthesia 2001;13(7):524-39 doi: 10.1016/S0952-8180(01)00320-8
5. Arneric SP, Laird JMA, Chappell AS, et al. Tailoring chronic pain treatments for the elderly: are we prepared for the challenge? Drug Discovery Today 2014;19(1):8-17 doi: 10.1016/j.drudis.2013.08.017
Rapid Response:
Re: Rates and risk factors for prolonged opioid use after major surgery: population based cohort study
Dear Sir,
Clarke et al. are concerned that 3.1% of patients over 65 years of age were receiving prescribed opioids 180 days following major surgery [1]. Our concern is that that figure may be too low if effective pain management is to be achieved.
First, the prevalence of moderate-to-severe chronic post-surgical pain (CPSP) in patients is rarely below 5% in epidemiological studies [2, 3]. This may extend to over 10% in thoracic surgery, coronary bypass graft, and hysterectomy – which accounted for more than half the cohort in Clarke’s study [1-3]. Although CPSP may be due to neuropathic pain, and require specific management, it is not unreasonable to suppose that many might also benefit from opioid therapy. Indeed opioids have been recognized as having a role to play in CPSP [4, 5].
Secondly, it is not clear if some of the 3% were actually suffering pain following re-operation for procedures linked to their initial operation – so somatic pain management would be entirely appropriate.
Thirdly, many of these patients will have been prescribed opioids given the increasingly well-recognized renal, gastrointestinal and cardiovascular contra-indications to NSAIDS in this age group.
Fourthly, the study was unable to address what proportion of patients were actually using the prescribed analgesics “as required”, or for “rescue analgesia”, and in what dosage. (Clearly there is a concern that patients may transfer opioid stocks to other uses, but this is probably more likely in a younger population).
While we appreciate that the dose and duration of opioids used for postoperative pain should be limited and subject to regular review, consideration of the balance of benefits versus side effects will in many cases require opioids to be continued under supervision. “Normal” practice from a statistical point of view suggests that 2.5% of patients would continue to require opioid analgesia…..3.1% is not far off!
Naheed JIVRAJ
MBBS Candidate, King's College London
MSc. International Health Policy (LSE)
Dr Colm LANIGAN MB BCh BAO DCH MRCPI MD FRCA FPM(RCOA)
Consultant Anaesthetist, University Hospital Lewisham, Lewisham & Greenwich Healthcare NHS Trust, London SE13 6LH.
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;348:g1251 doi: 10.1136/bmj.g1251
2. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet;367(9522):1618-25 doi: 10.1016/S0140-6736(06)68700-X
3. Macrae WA. Chronic post-surgical pain: 10 years on. British Journal of Anaesthesia 2008;101(1):77-86 doi: 10.1093/bja/aen099
4. Jin F, Chung F. Multimodal analgesia for postoperative pain control. Journal of Clinical Anesthesia 2001;13(7):524-39 doi: 10.1016/S0952-8180(01)00320-8
5. Arneric SP, Laird JMA, Chappell AS, et al. Tailoring chronic pain treatments for the elderly: are we prepared for the challenge? Drug Discovery Today 2014;19(1):8-17 doi: 10.1016/j.drudis.2013.08.017
Competing interests: No competing interests