Re: UK recommendations on opioid stewardship and Impact of COVID-19 on pain relieving operations and the need for expansion of non-pharmacological interventions
Re: UK recommendations on opioid stewardship and Impact of COVID-19 on pain relieving operations and the need for expansion of non-pharmacological interventions
Dear Editor
We thank Shania Liu and colleagues [1] for their interest in our editorial [2] on the need for better opioid stewardship programmes to prevent harm from opioid use and misuse. Whilst we discuss the need for opioid stewardship across all areas of opioid prescribing [2], they quite rightly reiterate that the surgical patient on opioids is at particular risk of persistent postoperative opioid use [1]. Recent evidence suggests that the risk of persistent postoperative opioid use in opioid naïve patients is 2-6%, whilst the incidence is more than 30% in those taking opioids prior to surgery [3]. Worryingly, preoperative opioid use has become increasingly common for surgical procedures aimed at relieving chronic non-cancer pain, with up to 84% of patients taking opioids in the year preceding surgery [4].
Liu and colleagues argue that the preoperative period is potentially an ideal time to wean opioids to improve surgical outcomes [1]. As healthcare professionals interested in utilising the whole of the perioperative period to improve surgical outcomes, we concur with these sentiments. It should be noted that the perioperative period extends from the moment of contemplation of surgery to complete recovery [5].
As well as there being evidence that the preoperative period is an ideal time to wean opioids to improve surgical outcomes, there is also increasing evidence that non-pharmacological interventions such as supervised and personalised exercise programmes are, at the very least, comparable to pharmacological interventions at relieving chronic non-cancer pain [6], and have additional health benefits, including increasing life expectancy [7]. The mechanism of exercise-induced analgesia is beginning to be understood [8].
Reliance on non-opioid interventions to manage chronic pain conditions are even more relevant in the COVID-19 era. In May 2020 it was estimated that at least 28 million surgical procedures have been cancelled worldwide due to COVID-19, and that it would take at least 45 weeks to clear this backlog if there was an 20% increase in baseline surgical activity [9]. Thus, it can be anticipated that with delayed treatment for pain relieving operations such as lower limb arthroplasties and surgery for chronic pancreatitis, the actual number of patients being commenced on opioids to manage their chronic pain will increase. These patients may not be able to obtain the full benefit of the surgical interventions, as they may become needlessly dependant on opioids. Thus, there is an urgent need to comply with national and international recommendations on the use of non-pharmacological strategies such as exercise and weight loss to manage painful conditions whilst waiting for the pain-relieving surgery [10-12].
In addition, there is a necessity to expand physiotherapy and weight reduction services to manage the influx of patients that require this service. Supervised prehabilitation programmes involving hospitals and communities may also help optimise patients physically, nutritionally and psychologically for surgery, resulting in better outcomes and, perhaps, easier weaning from opioids [13].
Moreover, opioids should only be considered as a last resort for chronic non-cancer pain, after appropriate shared decision making, and with a deprescribing plan agreed at the initial prescription as per the guidance of the Medicines and Health products Regulatory Agency [2,14].
References
1. Liu S, Blake E, Naylor J, et al. Rapid Response: Re: UK recommendations on opioid stewardship, 2021. https://www.bmj.com/content/372/bmj.m4901/rr (accessed 01/02/2021).
2. Levy N, Lord LJ, Lobo DN. UK recommendations on opioid stewardship. BMJ 2021; 372: m4901. doi: 10.1136/bmj.m4901 pmid: 33402365
3. Kent ML, Hurley RW, Oderda GM, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 joint consensus statement on persistent postoperative opioid use: definition, incidence, risk factors, and health care system initiatives. Anesth Analg 2019; 129: 543-52. doi: 10.1213/ANE.0000000000003941 pmid: 30897590
4. Lawal OD, Gold J, Murthy A, et al. Rate and risk factors associated with prolonged opioid use after surgery: a systematic review and meta-analysis. JAMA Netw Open 2020; 3: e207367. doi: 10.1001/jamanetworkopen.2020.7367 pmid: 32584407
5. Bougeard AM, Moore J. Delivering perioperative care in integrated care systems. Clin Med (Lond) 2019; 19: 450-3. doi: 10.7861/clinmed.2019.0241 pmid: 31732583
6. Henriksen M, Hansen JB, Klokker L, Bliddal H, Christensen R. Comparable effects of exercise and analgesics for pain secondary to knee osteoarthritis: a meta-analysis of trials included in Cochrane systematic reviews. J Comp Eff Res 2016; 5: 417-31. doi: 10.2217/cer-2016-0007 pmid: 27346368
7. Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380: 219-29. doi: 10.1016/S0140-6736(12)61031-9 pmid: 22818936
8. Lesnak JB, Sluka KA. Mechanism of exercise-induced analgesia: what we can learn from physically active animals. Pain Rep 2020; 5: e850. doi: 10.1097/PR9.0000000000000850 pmid: 33490844
9. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg 2020; 107: 1440-9. doi: 10.1002/bjs.11746 pmid 32395848
10. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain--United States, 2016. JAMA 2016; 315: 1624-45. doi: 10.1001/jama.2016.1464 pmid: 26977696
11. Centres for Disease Control and Prevention. Joint Pain and Arthritis, 2020. https://www.cdc.gov/arthritis/pain/index.htm (accessed 01/02/2021).
12. National Institute for Health and Care Excellence. Osteoarthritis: care and management, 2014. https://www.nice.org.uk/guidance/cg177/resources/osteoarthritis-care-and... (accessed 01/02/2021).
13. Levy N, Selwyn DA, Lobo DN. Turning 'waiting lists' for elective surgery into 'preparation lists'. Br J Anaesth 2021; 126: 1-5. doi: 10.1016/j.bja.2020.08.021 pmid: 32900503
14. Medicines and Healthcare products Regulatory Agency. Drug Safety Update 2020; 14 (2): 1-14. https://assets.publishing.service.gov.uk/government/uploads/system/uploa... (accessed 01/02/2021).
Competing interests:
No competing interests
01 February 2021
Nicholas A Levy
Consultant Anaesthetist
Mrs Linda Lord, Dr David Selwyn, Professor Dileep Lobo,
Rapid Response:
Re: UK recommendations on opioid stewardship and Impact of COVID-19 on pain relieving operations and the need for expansion of non-pharmacological interventions
Dear Editor
We thank Shania Liu and colleagues [1] for their interest in our editorial [2] on the need for better opioid stewardship programmes to prevent harm from opioid use and misuse. Whilst we discuss the need for opioid stewardship across all areas of opioid prescribing [2], they quite rightly reiterate that the surgical patient on opioids is at particular risk of persistent postoperative opioid use [1]. Recent evidence suggests that the risk of persistent postoperative opioid use in opioid naïve patients is 2-6%, whilst the incidence is more than 30% in those taking opioids prior to surgery [3]. Worryingly, preoperative opioid use has become increasingly common for surgical procedures aimed at relieving chronic non-cancer pain, with up to 84% of patients taking opioids in the year preceding surgery [4].
Liu and colleagues argue that the preoperative period is potentially an ideal time to wean opioids to improve surgical outcomes [1]. As healthcare professionals interested in utilising the whole of the perioperative period to improve surgical outcomes, we concur with these sentiments. It should be noted that the perioperative period extends from the moment of contemplation of surgery to complete recovery [5].
As well as there being evidence that the preoperative period is an ideal time to wean opioids to improve surgical outcomes, there is also increasing evidence that non-pharmacological interventions such as supervised and personalised exercise programmes are, at the very least, comparable to pharmacological interventions at relieving chronic non-cancer pain [6], and have additional health benefits, including increasing life expectancy [7]. The mechanism of exercise-induced analgesia is beginning to be understood [8].
Reliance on non-opioid interventions to manage chronic pain conditions are even more relevant in the COVID-19 era. In May 2020 it was estimated that at least 28 million surgical procedures have been cancelled worldwide due to COVID-19, and that it would take at least 45 weeks to clear this backlog if there was an 20% increase in baseline surgical activity [9]. Thus, it can be anticipated that with delayed treatment for pain relieving operations such as lower limb arthroplasties and surgery for chronic pancreatitis, the actual number of patients being commenced on opioids to manage their chronic pain will increase. These patients may not be able to obtain the full benefit of the surgical interventions, as they may become needlessly dependant on opioids. Thus, there is an urgent need to comply with national and international recommendations on the use of non-pharmacological strategies such as exercise and weight loss to manage painful conditions whilst waiting for the pain-relieving surgery [10-12].
In addition, there is a necessity to expand physiotherapy and weight reduction services to manage the influx of patients that require this service. Supervised prehabilitation programmes involving hospitals and communities may also help optimise patients physically, nutritionally and psychologically for surgery, resulting in better outcomes and, perhaps, easier weaning from opioids [13].
Moreover, opioids should only be considered as a last resort for chronic non-cancer pain, after appropriate shared decision making, and with a deprescribing plan agreed at the initial prescription as per the guidance of the Medicines and Health products Regulatory Agency [2,14].
References
1. Liu S, Blake E, Naylor J, et al. Rapid Response: Re: UK recommendations on opioid stewardship, 2021. https://www.bmj.com/content/372/bmj.m4901/rr (accessed 01/02/2021).
2. Levy N, Lord LJ, Lobo DN. UK recommendations on opioid stewardship. BMJ 2021; 372: m4901. doi: 10.1136/bmj.m4901 pmid: 33402365
3. Kent ML, Hurley RW, Oderda GM, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative-4 joint consensus statement on persistent postoperative opioid use: definition, incidence, risk factors, and health care system initiatives. Anesth Analg 2019; 129: 543-52. doi: 10.1213/ANE.0000000000003941 pmid: 30897590
4. Lawal OD, Gold J, Murthy A, et al. Rate and risk factors associated with prolonged opioid use after surgery: a systematic review and meta-analysis. JAMA Netw Open 2020; 3: e207367. doi: 10.1001/jamanetworkopen.2020.7367 pmid: 32584407
5. Bougeard AM, Moore J. Delivering perioperative care in integrated care systems. Clin Med (Lond) 2019; 19: 450-3. doi: 10.7861/clinmed.2019.0241 pmid: 31732583
6. Henriksen M, Hansen JB, Klokker L, Bliddal H, Christensen R. Comparable effects of exercise and analgesics for pain secondary to knee osteoarthritis: a meta-analysis of trials included in Cochrane systematic reviews. J Comp Eff Res 2016; 5: 417-31. doi: 10.2217/cer-2016-0007 pmid: 27346368
7. Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012; 380: 219-29. doi: 10.1016/S0140-6736(12)61031-9 pmid: 22818936
8. Lesnak JB, Sluka KA. Mechanism of exercise-induced analgesia: what we can learn from physically active animals. Pain Rep 2020; 5: e850. doi: 10.1097/PR9.0000000000000850 pmid: 33490844
9. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg 2020; 107: 1440-9. doi: 10.1002/bjs.11746 pmid 32395848
10. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain--United States, 2016. JAMA 2016; 315: 1624-45. doi: 10.1001/jama.2016.1464 pmid: 26977696
11. Centres for Disease Control and Prevention. Joint Pain and Arthritis, 2020. https://www.cdc.gov/arthritis/pain/index.htm (accessed 01/02/2021).
12. National Institute for Health and Care Excellence. Osteoarthritis: care and management, 2014. https://www.nice.org.uk/guidance/cg177/resources/osteoarthritis-care-and... (accessed 01/02/2021).
13. Levy N, Selwyn DA, Lobo DN. Turning 'waiting lists' for elective surgery into 'preparation lists'. Br J Anaesth 2021; 126: 1-5. doi: 10.1016/j.bja.2020.08.021 pmid: 32900503
14. Medicines and Healthcare products Regulatory Agency. Drug Safety Update 2020; 14 (2): 1-14. https://assets.publishing.service.gov.uk/government/uploads/system/uploa... (accessed 01/02/2021).
Competing interests: No competing interests