New international consensus statements pave the way for opioid-sparing protocols in surgery patients. The American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) calls for opioid-free intraoperative management in patients who have been exposed to opioids or who have other risk factors.1
There are three parts to the consensus on opioids and surgery, including one on perioperative management, a second on operative management of patients who have been taking opioids, and a third on management of opioids for patients who are opioid-naïve, says David A. Edwards, PhD, MD, assistant professor, Vanderbilt University Medical Center. The consensus statements cover presurgery, intrasurgery, and postsurgery.
“We did a systematic review of all the literature that discusses management and risks for patients around opioids and surgery,” Edwards says. The paper’s authors graded the quality of studies and examined descriptions of opioid risks to see if these were analyzed by subgroups in the research. “We graded all the evidence, and based on all of that evidence, we came up with the consensus guidelines,” Edwards explains.
Before surgery, the consensus authors recommend that patients who are at high risk undergo a presurgical specialist consultation with an addiction psychologist, psychiatrist, or pain management provider. The goal is to set the patient’s expectations and to identify their risk factors for opioid misuse, Edwards says. “One of the risks for people on opioids is uncontrolled anxiety,” he notes. “If you don’t manage those things and set expectations, then patients use opioids to manage anxiety and depression.”
Investigators categorized the various risk factors for persistent postoperative opioid use, finding that preoperative opioid use and depression have the greatest level of evidence. Substance use, preoperative pain condition, and smoking also are risk factors with a high level of evidence. Some evidence also suggests that anxiety, sex, and psychotropic drug use pose a risk.2 Knowing patients’ risk factors is important because even opioid-naïve patients could end up with a long-term opioid problem, Edwards notes.
“A single exposure to opioids can prime some people to seek it further,” he says. “They are in a high-risk group, and we might not know who they are, but maybe they have a genetic predilection for it.”
The working group that examined persistent postoperative opioid use found that surgical patients who were preoperative opioid users were 10 times more likely to develop persistent postoperative opioid use than opioid-naïve patients following arthroplasty and abdominopelvic procedures.2 Some are finding that patients who have been taking opioids before their first visit with a surgeon will fare better with postsurgery pain management and medication side effects if their opioid prescriptions are tapered before the procedure. Then, when these patients are prescribed new pain medications after surgery, they will not need such strong doeses of opioids as they would have without pre-op tapering.
“They are less likely to have side effects and complications,” Edwards says. “There is less risk of respiratory arrest, and the lower the dose a person is discharged with, the less likely they are to be on opioids long term.” The consensus paper addresses management of patients on opioids and how to discharge patients with fewer opioid pills. For instance, surgery centers could use multimodal treatments, keeping drugs at low doses, and employing nonmedication approaches, Edwards says. Expectation management is crucial. “Everyone is different and deals with the stress of surgery differently,” he adds.
Surgeons can assess patients’ catastrophizing scores. Those with high catastrophizing scores are likely to use opioids and experience worse outcomes relative to surgical pain. “You need to recognize those people and support them all the way through the process,” Edwards says. “Maybe they can see a psychologist or receive enhancement service, holding their hands a little more and communicating with them.”
For opioid-naïve patients, the optimal method is to help them manage their pain without use of opioids. “If someone is opioid-naïve, and you can keep them opioid naïve, that’s a good thing as long as their pain is controlled,” Edwards says. “A lot of major centers develop opioid-free pathways. In principle, this paper deals with that.”
For intrasurgery, the consensus paper discusses blocks and spinal and regional anesthesia. There are multiple medical approaches and potent medications that would spare opioids, including ketorolac, an IV nonsteroidal anti-inflammatory drug that can be as effective at managing pain as 10 to 15 mg of IV opioids, Edwards offers.
The consensus guidelines provide pathways and suggestions for surgery centers and other healthcare groups that want to begin opioid-sparing regimens that are based on the best available evidence. “Outside of academic centers and progressive centers, the major pain medication during surgery still is an opioid. The main opioid is fentanyl,” Edwards says. “We all know that fentanyl is the number one abused drug in opioid overdoses right now.” But if physicians can avoid using fentanyl, they should. Instead of fentanyl, they could use ketamine infusions, lidocaine, or other drugs, Edwards suggests. “Even major spine fusions can be done without opioids,” he adds.
- Edwards DA, Hedrick TL, Jayaram J, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on perioperative management of patients on preoperative opioid therapy. Anesth Analg 2019; Apr 15. doi: 10.1213/ANE.0000000000004018. [Epub ahead of print].
- Kent ML, Hurley RW, Orderda 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; Apr 15. doi: 10.1213/ANE.0000000000003941. [Epub ahead of print].