Re: Prolonged use of opioids after surgery
The paper by Clarke et al (1) highlights another area where the use of opioids for the treatment of pain may be problematic. It is unfortunate that the accompanying editorial analysis does not highlight the complexity of the surrounding issues (2). Health care systems are often protocol driven and early discharge following surgery is encouraged to reduce cost. It is unsurprising that patients are therefore more commonly discharged on stronger analgesic agents. Nor is it surprising that the systems to ensure timely review of analgesia are not robust. Society is becoming less tolerant of any form of prolonged suffering and this can lead to a demand for (surgical) solutions, where they may not exist. The maxim that “a good surgeon knows how to operate; a better surgeon knows when not to operate” seems to have been lost in our pursuit of efficiency. Recent work attests to the fact that, for many, chronic post surgical pain is often a continuation of an ongoing pain problem (2).
Ongoing pain is a complex mixture of physical, psychological and social problems. Postoperative pain is an area where the use of opioids has a strong evidence base and they alleviate significant suffering It is simplistic to assume, that in the prolonged postoperative phase, this pain is mainly neuropathic in nature. Indeed, in the example put forward - chronic post thoracic surgical pain - a neuropathic component has been shown in only two thirds of patients (3). The evidence for opioid induced hyperalgesia is predominantly from basic science and has a limited clinical evidence base. It is more likely to be seen in the high doses used in the end stages of palliative care than in the postoperative period, unless patients present on high opioid doses prior to surgery.
The possible solutions proposed by Dualé, namely the use of adjuvant agents, lack a firm evidence base in both treating and preventing ongoing pain (4, 5). The scientific study of these drugs in acute pain has been associated with hidden data, publication bias and in some cases, fraudulent research. It is increasingly recognised that the long term use of some adjuvant agents can be associated with similar problems of dependence and addiction as occur with opioids. .
Anaesthetists and surgeons are now realising that post surgical pain, like any chronic pain, is a complex biopsychosocial problem.
As with surgery, any analysis of the significant problem of prolonged postoperative opioid use in the community needs to be incisive and should aim to restrict unwanted collateral damage.
1. Clarke H, et al. "Rates and risk factors for prolonged opioid use after major surgery: population based cohort study." BMJ: British Medical Journal 348 (2014).
2. Dualé, C. "Prolonged use of opioids after surgery." BMJ: British Medical Journal 348 (2014).
3. Johansen A,, et al. "Persistent post-surgical pain and experimental pain sensitivity in the Tromsø study: Comorbid pain matters." Pain 155.2 (2014): 341-348.
4. Haroutiunian S, et al. "The neuropathic component in persistent postsurgical pain: a systematic literature review." Pain 154.1 (2013): 95-102.
5. Straube, S, et al. "Single dose oral gabapentin for established acute postoperative pain in adults." Cochrane Database Syst Rev 5 (2010).
6. Chaparro, L E, et al. "Pharmacotherapy for the prevention of chronic pain after surgery in adults." Cochrane Database Syst Rev 7 (2013).
Competing interests: Both MB and CR have previously received honorarium for presenting at meetings sponsored by pharmaceutical companies that promoted both gabapentinoids and opiates in pain