Re: Prolonged use of opioids after surgery
Both the original article and the accompanying editorial raise a number of important issues regarding the prolonged use of opioids after surgery, and potential alternative analgesics. We would however like to expand on the most likely main underlying cause, namely persistent postsurgical pain (PPP).
Since Macrae and colleagues alerted us fifteen years ago to the incidence of PPP, there has been growing awareness and acceptance of this problem, in particular following thoracic, breast, knee and inguinal hernia surgery (1). Aside from the site of surgery, the strongest and most consistently reported predictor of developing PPP has been worse acute pain, with patient phenotype, such as pain sensitivity on quantitative sensory testing and psychological factors, also proving predictive.
We too are concerned by the high incidence of opioid use long after the expected period for healing and resolution, but feel that the majority results from PPP. It is important therefore to recognise the potential benefit of perioperative care in preventing PPP, and hence reducing the need for prolonged analgesic use.
There is an unlikely to be a single agent or class of drugs, which can act as a panacea, in either the prevention or treatment of PPP - neuropathic or otherwise. However, both gabapentinoids and ketamine have received favourable assessment in these roles (2-4) but are yet to be studied extensively in multimodal regimens. These studies are difficult to design but have proved fruitful when done well in other neuropathic pain conditions (5, 6).
The constellation of symptoms attributed to PPP following chest surgery, as one example, can itself be incredibly variable: ranging from sternal malunion, dislocation, rib fracture, shoulder pain as well as classic incisional pain, alongside many others descriptors and trajectories. A recent six year follow up study of over 2000 breast surgery patients revealed that 15% of those pain free at year two had subsequently developed peri-incisional pain at year six (7)
We would advocate perioperative, short-term use of use of ketamine and/or gabapentinoids to improve acute pain, reduce opioid requirement and potentially prevent the progression to PPP. It is likely that the same mechanisms contributing to difficult acute postsurgical pain also lead to the development of pain persistence, well beyond the expected duration of wound healing (8)
A multimodal and patient specific approach is therefore likely to be required- and opioids may well feature as part of that long-term treatment. Currently however they seem to form monotherapy, often in the absence of the appreciation of alternatives, and rather than dose perpetuation and escalation, much more attention should be given to reassessment, down-titration and discontinuation of opioid therapy. These are issues for primary as well as secondary care. We should also ensure that post-operative patients are informed of the expected course for their pain and should be advised to seek medical advice regarding pain control at an earlier stage.
1. Crombie IK, Davies HT, Macrae WA. Cut and thrust: antecedent surgery and trauma among patients attending a chronic pain clinic. Pain 1998;76:167-71.
2. Clarke H, Bonin RP, Orser BA, Englesakis M, Wijeysundera DN, Katz J. The Prevention of Chronic Postsurgical Pain Using Gabapentin and Pregabalin. Anesthesia & Analgesia 2012;115:428-42.
3. Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I. Pharmacotherapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst Rev. 2013;7:CD008307.
4. Schmidt PC, Ruchelli G, Mackey SC, Carroll IR. Perioperative gabapentinoids: choice of agent, dose, timing, and effects on chronic postsurgical pain. Anesthesiology 2013;119:1215-21.
5. Gilron I, Bailey JM, Tu D, Holden RR, Weaver DF, Houlden RL. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J Med 2005;352:1324-34.
6. Gilron I, Bailey JM, Tu D, Holden RR, Jackson AC, Houlden RL. Nortriptyline and gabapentin, alone and in combination for neuropathic pain: a double-blind, randomised controlled crossover trial. Lancet 2009;374:1252-61.
7. Mejdahl MK, Andersen KG, Gartner R, Kroman N, Kehlet H. Persistent pain and sensory disturbances after treatment for breast cancer: six year nationwide follow-up study. BMJ 2013;346:f1865.
8. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: risk factors and prevention. The Lancet. 2006;367:1618-25.
Competing interests: No competing interests