Lancet Article Series on Postoperative Pain Management Practices

A series of 3 articles published in the Lancet is dedicated to highlighting the nature of current postsurgical pain management practices, including the use of peri- and postoperative opioids, that are thought to play a part in driving the opioid crisis occurring in North America and Australia, as well as strategies to improve those practices and mitigate associated adverse outcomes.^1-3

The first article by Australian researchers provides a comprehensive overview of the clinical features, prevalence, prognosis, mechanisms, and predictors of chronic postsurgical pain (CPSP).¹ Approaches seeking to prevent the transition from acute pain to CPSP, the role of “transitional” pain clinics in preventing CPSP, and the treatment of established CPSP are also covered. “CPSP is similar to other chronic pain and therefore requires a comprehensive biopsychosocial approach to treatment. Transitional pain clinics are a new approach [in an effort to] bridg[e] the divide, with elimination of overprescribing of opioids after surgery being a major goal,” noted the researchers.

In the second article, the inappropriate prescription of opioids to postsurgical patients is examined.² In particular, the investigators highlight the trends in recent years favoring increases in opioid prescribing, including overprescribing of these drugs for the management of postsurgical pain. They also discuss adverse outcomes associated with such practices, including misuse, risk for diversion, the occurrence of opioid use disorder, strategies to avoid such practices and their related effects, as well as policies that have sought to address inappropriate prescribing of opioids for the management of acute pain. “[E]fforts are ongoing to identify and implement effective interventions at the patient level, health system level, and policy level to discourage excess opioid prescribing and prevent related misuse and diversion,” noted the article authors.

In the last article of the series, dedicated to the perioperative use of opioid analgesia, investigators sought to highlight 2 phenomena associated with the long-term use of these drugs: tolerance and opioid-induced hyperalgesia, both of which can be associated with escalation of opioid doses and inadequate pain management.³ “By improving [the] understanding of the underlying mechanisms, it might be possible to develop strategies to identify and better manage postoperative pain and pain after injury, to improve safety and efficacy of opioid use, and to minimize long-term harm,” noted the authors.

The use of opioids in an acute setting can affect 3 types of patients:

1. Patients already taking opioids who may already be tolerant to the drug and in whom pain management with this modality may not be optimal. These patients may also experience opioid-induced hyperalgesia. In this population, use of alternative pain management strategies combined with lower doses of opioids is recommended.

2. In opioid-naive patients, perioperative use of short-acting opioids may also lead to opioid-induced hyperalgesia, as well as acute tolerance to the drug. In addition, these patients may experience acute withdrawal upon rapid cessation.

3. Patients to whom opioids are prescribed in an effort to discharge them early may experience physical and psychological dependence when they are prescribed opioids for long periods postoperatively. The researchers pointed to several research gaps that hamper efforts to improve perioperative pain management, including the identification of analgesic approaches seeking to take advantage of endogenous pain mechanisms.

In an editorial accompanying the article series, researchers commend the formulation by authors of the 3 articles of strategies “that can be implemented on many levels from drug discovery to direct communication with patients, all the way to legislative action.”⁴

References

1. Glare P, Aubrey KR, Myles PS. Transition from acute to chronic pain after surgery. Lancet. 2019; 393:1537-1546.
2. Neuman MD, Bateman BT, Wunsch H. Inappropriate opioid prescription after surgery. Lancet. 2019; 393:1547-1557.
3. Colvin LA, Bull F, Hales TG. Perioperative opioids analgesia — when is enough too much? A review of opioid-induced tolerance and hyperalgesia. Lancet. 2019; 393:1558-1568.
4. Hollman MW, Rathmell JP, Lirk P. Optimal postoperative pain management: redefining the role for opioids. Lancet. 2019; 393:1483-1485.

This article originally appeared on Clinical Pain Advisor