We thank Nicholas Levy and colleagues for their timely and insightful Editorial entitled “UK recommendations on opioid stewardship”.(1) The authors outline the harms associated with opioid misuse and subsequent recommendations made by the UK Medicines and Healthcare Products Regulatory Agency to encourage appropriate opioid use. In particular, the Editorial highlights the limited role of opioids for chronic non-cancer pain and that opioids used for this indication should be prescribed with an end date planned. We wish to elaborate on this point by asserting that a key opportunity for such deprescribing exists among surgical patients. Opioid use during surgery has been a long-standing issue with large variations in practice and many patients remaining on opioids 12 months after surgery.(2) Furthermore, pre-operative opioid use has become increasingly common for surgeries aimed at relieving chronic non-cancer pain, with up to 84% of patients taking opioids in the year preceding surgery.(3)
Similar patterns are observed among patients undergoing hip or knee arthroplasty,(4,5) despite opioids limited benefit in osteoarthritis and risks of adverse events.(6-9) A literature review of opioid use before arthroplasty reported an association between preoperative opioid use and worse postoperative pain and surgical outcomes.(9) Importantly, evidence from retrospective administrative healthcare data demonstrated that these effects may be reversible if opioids were weaned (by at least 50%) prior to arthroplasty.(10) However, due to the retrospective nature of this study, how and why opioids were weaned could not be determined. Given patients awaiting elective surgery have a theorised ‘end point’ determined by their surgery date and increased engagement with the health system before and after surgery, we propose that opioid tapering prior to elective surgeries such as arthroplasty is currently a missed opportunity which may be leveraged for significant public health benefit.
Despite the apparent sound arguments for weaning, a 2017 Cochrane review highlighted the paucity of literature on the efficacy of interventions to reduce opioid use for chronic non-cancer pain.(11) Furthermore, our group conducted a systematic review in 2020 of prospective studies to examine the effectiveness of interventions to reduce opioids for non-cancer pain prior to elective surgery (PROSPERO ID: CRD42020202221). We searched seven electronic databases; Medline, Scopus, Embase, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, PsycINFO and Cumulative Index of Nursing and Allied Health Literature (CINAHL), retrieving 4,088 articles. Surprisingly, no relevant studies were found. Not surprisingly, informative policies are lacking regarding preoperative opioid tapering for any elective surgery.
There appears to be more research conducted in reducing opioid use after surgery instead of preventing the issue altogether by weaning patients off opioids before the surgery. One randomised controlled trial on postoperative opioid tapering after orthopaedic surgery aimed to reduce opioid use to baseline preoperative use has been published but none exist for preoperative opioid tapering.(12) We propose interventions to preoperatively taper patients’ baseline opioid use would be even more resource-efficient and achieve greater clinical benefit. Taking the recommendations of Levy et al. regarding slow opioid tapering after prolonged treatment one step further, we assert that the preoperative period offers a longer timespan to taper opioids than the typically shorter postoperative period prior to hospital discharge or review, thus reducing the risk of acute opioid withdrawal following extended opioid. High-level studies to examine the efficacy of interventions on preoperative reduction of opioid use before elective hip or knee arthroplasty, or any elective surgery, are warranted. If shown to be cost-effective for the individual and healthcare provider, societal benefits are likely to follow.
References
1. Levy N, Lord LJ, Lobo DN. UK recommendations on opioid stewardship.
2. Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. The Lancet. 2019 Apr 13;393(10180):1547-57.
3. Lawal, O. D., Gold, J., Murthy, A., Ruchi, R., Bavry, E., Hume, A. L., Wen, X. (2020). Rate and Risk Factors Associated With Prolonged Opioid Use After Surgery: A Systematic Review and Meta-analysis. JAMA Network Open, 3(6), e207367-e207367. doi:10.1001/jamanetworkopen.2020.7367
4. Stevens J. Inadvertent post-operative opioid use. Australian Orthopaedic Association. 2018.
5. Penm J et al. Harms and costs of opioid related adverse events in hip and knee replacements (under review). 2019.
6. Avouac J, Gossec L, Dougados M. Efficacy and safety of opioids for osteoarthritis: a meta-analysis of randomized controlled trials. Osteoarthritis and Cartilage 2007;15:957-65.
7. Naylor, J.M., Pavlovic, N., Farrugia, M, Ogul S, Hackett D, Wan A, Adie S, Brady B, Gray L, Wright R, Nazar M, Xuan W. Associations between pre-surgical daily opioid use and short-term outcomes following knee or hip arthroplasty: a prospective, exploratory cohort study. BMC Musculoskelet Disord 21, 398 (2020). https://doi.org/10.1186/s12891-020-03413-z
8. Smith SR, Deshpande BR, Collins JE, Katz JN, Losina E. Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review. Osteoarthritis and cartilage 2016;24:962-72.
9. Goplen CM, Verbeek W, Kang SH, Jones CA, Voaklander DC, Churchill TA, et al. Preoperative opioid use is associated with worse patient outcomes after total joint arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20:234.
10. Nguyen L-CL, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty. The Journal of arthroplasty 2016;31:282-7.
11. Eccleston C, Fisher E, Thomas KH, Hearn L, Derry S, Stannard C, Knaggs R, Moore RA. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD010323. DOI: 10.1002/14651858.CD010323.pub3.
12. Hah JM, Trafton JA, Narasimhan B, Krishnamurthy P, Hilmoe H, Sharifzadeh Y, Huddleston JI, Amanatullah D, Maloney WJ, Goodman S, Carroll I. Efficacy of motivational-interviewing and guided opioid tapering support for patients undergoing orthopedic surgery (MI-Opioid Taper): A prospective, assessor-blind, randomized controlled pilot trial. EClinicalMedicine. 2020 Nov 1;28:100596.
Competing interests:
No competing interests
15 January 2021
Shania Liu
Pharmacist
Emma Blake, Justine Naylor, Sam Adie, Asad Patanwala, Jennifer Stevens, Bernadette Brady, Jonathan Penm
A15 – Pharmacy and Bank Building, The University of Sydney, Camperdown, NSW, Australia
Rapid Response:
Re: UK recommendations on opioid stewardship
Dear Editor,
We thank Nicholas Levy and colleagues for their timely and insightful Editorial entitled “UK recommendations on opioid stewardship”.(1) The authors outline the harms associated with opioid misuse and subsequent recommendations made by the UK Medicines and Healthcare Products Regulatory Agency to encourage appropriate opioid use. In particular, the Editorial highlights the limited role of opioids for chronic non-cancer pain and that opioids used for this indication should be prescribed with an end date planned. We wish to elaborate on this point by asserting that a key opportunity for such deprescribing exists among surgical patients. Opioid use during surgery has been a long-standing issue with large variations in practice and many patients remaining on opioids 12 months after surgery.(2) Furthermore, pre-operative opioid use has become increasingly common for surgeries aimed at relieving chronic non-cancer pain, with up to 84% of patients taking opioids in the year preceding surgery.(3)
Similar patterns are observed among patients undergoing hip or knee arthroplasty,(4,5) despite opioids limited benefit in osteoarthritis and risks of adverse events.(6-9) A literature review of opioid use before arthroplasty reported an association between preoperative opioid use and worse postoperative pain and surgical outcomes.(9) Importantly, evidence from retrospective administrative healthcare data demonstrated that these effects may be reversible if opioids were weaned (by at least 50%) prior to arthroplasty.(10) However, due to the retrospective nature of this study, how and why opioids were weaned could not be determined. Given patients awaiting elective surgery have a theorised ‘end point’ determined by their surgery date and increased engagement with the health system before and after surgery, we propose that opioid tapering prior to elective surgeries such as arthroplasty is currently a missed opportunity which may be leveraged for significant public health benefit.
Despite the apparent sound arguments for weaning, a 2017 Cochrane review highlighted the paucity of literature on the efficacy of interventions to reduce opioid use for chronic non-cancer pain.(11) Furthermore, our group conducted a systematic review in 2020 of prospective studies to examine the effectiveness of interventions to reduce opioids for non-cancer pain prior to elective surgery (PROSPERO ID: CRD42020202221). We searched seven electronic databases; Medline, Scopus, Embase, Cochrane Central Register of Controlled Trials, International Pharmaceutical Abstracts, PsycINFO and Cumulative Index of Nursing and Allied Health Literature (CINAHL), retrieving 4,088 articles. Surprisingly, no relevant studies were found. Not surprisingly, informative policies are lacking regarding preoperative opioid tapering for any elective surgery.
There appears to be more research conducted in reducing opioid use after surgery instead of preventing the issue altogether by weaning patients off opioids before the surgery. One randomised controlled trial on postoperative opioid tapering after orthopaedic surgery aimed to reduce opioid use to baseline preoperative use has been published but none exist for preoperative opioid tapering.(12) We propose interventions to preoperatively taper patients’ baseline opioid use would be even more resource-efficient and achieve greater clinical benefit. Taking the recommendations of Levy et al. regarding slow opioid tapering after prolonged treatment one step further, we assert that the preoperative period offers a longer timespan to taper opioids than the typically shorter postoperative period prior to hospital discharge or review, thus reducing the risk of acute opioid withdrawal following extended opioid. High-level studies to examine the efficacy of interventions on preoperative reduction of opioid use before elective hip or knee arthroplasty, or any elective surgery, are warranted. If shown to be cost-effective for the individual and healthcare provider, societal benefits are likely to follow.
References
1. Levy N, Lord LJ, Lobo DN. UK recommendations on opioid stewardship.
2. Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. The Lancet. 2019 Apr 13;393(10180):1547-57.
3. Lawal, O. D., Gold, J., Murthy, A., Ruchi, R., Bavry, E., Hume, A. L., Wen, X. (2020). Rate and Risk Factors Associated With Prolonged Opioid Use After Surgery: A Systematic Review and Meta-analysis. JAMA Network Open, 3(6), e207367-e207367. doi:10.1001/jamanetworkopen.2020.7367
4. Stevens J. Inadvertent post-operative opioid use. Australian Orthopaedic Association. 2018.
5. Penm J et al. Harms and costs of opioid related adverse events in hip and knee replacements (under review). 2019.
6. Avouac J, Gossec L, Dougados M. Efficacy and safety of opioids for osteoarthritis: a meta-analysis of randomized controlled trials. Osteoarthritis and Cartilage 2007;15:957-65.
7. Naylor, J.M., Pavlovic, N., Farrugia, M, Ogul S, Hackett D, Wan A, Adie S, Brady B, Gray L, Wright R, Nazar M, Xuan W. Associations between pre-surgical daily opioid use and short-term outcomes following knee or hip arthroplasty: a prospective, exploratory cohort study. BMC Musculoskelet Disord 21, 398 (2020). https://doi.org/10.1186/s12891-020-03413-z
8. Smith SR, Deshpande BR, Collins JE, Katz JN, Losina E. Comparative pain reduction of oral non-steroidal anti-inflammatory drugs and opioids for knee osteoarthritis: systematic analytic review. Osteoarthritis and cartilage 2016;24:962-72.
9. Goplen CM, Verbeek W, Kang SH, Jones CA, Voaklander DC, Churchill TA, et al. Preoperative opioid use is associated with worse patient outcomes after total joint arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord. 2019;20:234.
10. Nguyen L-CL, Sing DC, Bozic KJ. Preoperative reduction of opioid use before total joint arthroplasty. The Journal of arthroplasty 2016;31:282-7.
11. Eccleston C, Fisher E, Thomas KH, Hearn L, Derry S, Stannard C, Knaggs R, Moore RA. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database of Systematic Reviews 2017, Issue 11. Art. No.: CD010323. DOI: 10.1002/14651858.CD010323.pub3.
12. Hah JM, Trafton JA, Narasimhan B, Krishnamurthy P, Hilmoe H, Sharifzadeh Y, Huddleston JI, Amanatullah D, Maloney WJ, Goodman S, Carroll I. Efficacy of motivational-interviewing and guided opioid tapering support for patients undergoing orthopedic surgery (MI-Opioid Taper): A prospective, assessor-blind, randomized controlled pilot trial. EClinicalMedicine. 2020 Nov 1;28:100596.
Competing interests: No competing interests