Evolving the Management of Acute Perioperative Pain Towards Opioid Free Protocols: A Narrative Review
Abstract
Objective: Identification of pain as the fifth vital sign has resulted in over-prescription and overuse of opioids in the United States (US), with addiction reaching epidemic proportions. In Europe, and more recently in the US, a shift has occurred with the global adoption of multimodal analgesia (MMA), which seeks to minimize perioperative opioid use. Improved functional outcomes and reduced healthcare utilization costs have been demonstrated with MMA, but wide-scale use of opioids in pain management protocols continues. As a next step in the pain management evolution, opioid-free analgesia (OFA) MMA strategies have emerged as feasible in many surgical settings.
Methods: A MEDLINE search for articles published within the last 10 years was performed using the terms “opioid” and “acute pain” or “post(-)operative pain”. Articles were limited to clinical studies and meta-analyses focusing on comparisons between opioid-intensive and opioid‑free/opioid-sparing strategies published in English.
Results: In this review, elimination or substantial reduction in opioid use with OFA strategies for perioperative acute pain are discussed, with an emphasis on improved pain control and patient satisfaction. Improved functional outcomes and patient recovery as well as reduced healthcare utilization costs also are discussed, along with challenges facing implementation of such strategies.
Conclusions: Effective MMA strategies have paved the way for OFA approaches to postoperative pain management, with goals to reduce opioid prescriptions, improve patient recovery, and reduce overall healthcare resource utilization and costs. However, institution-wide deployment and adoption of OFA still is in early stages and will require personalization and better management of patient expectations.
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References
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[5] J.J. Savarese, N.G. Tabler, Jr., Multimodal analgesia as an alternative to the risks of opioid monotherapy in surgical pain management, J Healthc Risk Manag. 37(1) (2017) 24-30.
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[7] E.C. Sun, B.D. Darnall, L.C. Baker, et al., Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period, JAMA Intern Med. 176(9) (2016) 1286-93.
[8] T.J. Gan, A.S. Habib, T.E. Miller, et al., Incidence, patient satisfaction, and perceptions of post-surgical pain: results from a US national survey, Current medical research and opinion. 30(1) (2014) 149-60.
[9] E. Onishi, T. Kobayashi, E. Dexter, et al., Comparison of Opioid Prescribing Patterns in the United States and Japan: Primary Care Physicians' Attitudes and Perceptions, J Am Board Fam Med. 30(2) (2017) 248-254.
[10] C.M. Brummett, J.F. Waljee, J. Goesling, et al., New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults, JAMA surgery. 152(6) (2017) e170504.
[11] J.A. Hoppe, H. Kim, K. Heard, Association of emergency department opioid initiation with recurrent opioid use, Ann Emerg Med. 65(5) (2015) 493-499 e4.
[12] E.K. Aasvang, T.H. Lunn, T.B. Hansen, et al., Chronic pre-operative opioid use and acute pain after fast-track total knee arthroplasty, Acta Anaesthesiol Scand. 60(4) (2016) 529-36.
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[16] E.E. Shaffer, A. Pham, R.L. Woldman, et al., Estimating the Effect of Intravenous Acetaminophen for Postoperative Pain Management on Length of Stay and Inpatient Hospital Costs, Adv Ther. 33(12) (2017) 2211-2228.
[17] M. Melnyk, R.G. Casey, P. Black, et al., Enhanced recovery after surgery (ERAS) protocols: Time to change practice?, Can Urol Assoc J. 5(5) (2011) 342-8.
[18] B.O. Herring, S. Ader, A. Maldonado, et al., Impact of intravenous acetaminophen on reducing opioid use after hysterectomy, Pharmacotherapy. 34 Suppl 1 (2014) 27S-33S.
[19] S. Saurabh, J.K. Smith, M. Pedersen, et al., Scheduled intravenous acetaminophen reduces postoperative narcotic analgesic demand and requirement after laparoscopic Roux-en-Y gastric bypass, Surg Obes Relat Dis. 11(2) (2015) 424-30.
[20] K. Song, M.J. Melroy, O.C. Whipple, Optimizing multimodal analgesia with intravenous acetaminophen and opioids in postoperative bariatric patients, Pharmacotherapy. 34 Suppl 1 (2014) 14S-21S.
[21] Y. Tunali, E.F. Akcil, O.K. Dilmen, et al., Efficacy of intravenous paracetamol and dexketoprofen on postoperative pain and morphine consumption after a lumbar disk surgery, J Neurosurg Anesthesiol. 25(2) (2013) 143-7.
[22] L.A. McQueen-Shadfar, S.A. Megalla, W.D. White, et al., Impact of intraoperative dexmedetomidine on postoperative analgesia following gynecologic surgery, Curr Med Res Opin. 27(11) (2011) 2091-7.
[23] J.A. Warren, C. Stoddard, A.L. Hunter, et al., Effect of Multimodal Analgesia on Opioid Use After Open Ventral Hernia Repair, J Gastrointest Surg. 21(10) (2017) 1692-1699.
[24] J. Hah, S.C. Mackey, P. Schmidt, et al., Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial, JAMA Surg. (2017).
[25] R.M. Langford, G.P. Joshi, T.J. Gan, et al., Reduction in opioid-related adverse events and improvement in function with parecoxib followed by valdecoxib treatment after non-cardiac surgery: a randomized, double-blind, placebo-controlled, parallel-group trial, Clin Drug Investig. 29(9) (2009) 577-90.
[26] J.M. Feld, C.E. Laurito, M. Beckerman, et al., Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery, Can J Anaesth. 50(4) (2003) 336-41.
[27] E. Farag, M. Ghobrial, D.I. Sessler, et al., Effect of perioperative intravenous lidocaine administration on pain, opioid consumption, and quality of life after complex spine surgery, Anesthesiology. 119(4) (2013) 932-40.
[28] N. Elia, C. Lysakowski, M.R. Tramer, Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials, Anesthesiology. 103(6) (2005) 1296-304.
[29] I. Wong, C. St John-Green, S.M. Walker, Opioid-sparing effects of perioperative paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs) in children, Paediatric anaesthesia. 23(6) (2013) 475-95.
[30] L. Rodriguez-Rubio, E. Nava, J.S.G. Del Pozo, et al., Influence of the perioperative administration of magnesium sulfate on the total dose of anesthetics during general anesthesia. A systematic review and meta-analysis, J Clin Anesth. 39 (2017) 129-138.
[31] C.C. Apfel, K. Souza, J. Portillo, et al., Patient satisfaction with intravenous acetaminophen: a pooled analysis of five randomized, placebo-controlled studies in the acute postoperative setting, J Healthc Qual. 37(3) (2015) 155-62.
[32] S. S. Hontoir, P. Saxena, M.K. Gatto, et al., Opioid-free anesthesia: what about patient comfort? A prospective, randomized, controlled trial, Acta Anaesth. Belg. 67 183-190.
[33] K. Maheshwari, K.C. Cummings, 3rd, E. Farag, et al., A temporal analysis of opioid use, patient satisfaction, and pain scores in colorectal surgery patients, J Clin Anesth. 34 (2016) 661-7.
[34] H.S. Kim, P.M. Lank, P.S. Pang, et al., ED opioid prescribing is not associated with higher patient satisfaction scores, Am J Emerg Med. 34(10) (2016) 2032-2034.
[35] J.F. Barletta, Clinical and economic burden of opioid use for postsurgical pain: focus on ventilatory impairment and ileus, Pharmacotherapy. 32(9 Suppl) (2012) 12s-8s.
[36] E.R. Kessler, M. Shah, S.K. Gruschkus, et al., Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes, Pharmacotherapy. 33(4) (2013) 383-91.
[37] B.A. Maiese, A.T. Pham, M.V. Shah, et al., Hospitalization Costs for Patients Undergoing Orthopedic Surgery Treated With Intravenous Acetaminophen (IV-APAP) Plus Other IV Analgesics or IV Opioid Monotherapy for Postoperative Pain, Adv Ther. 34(2) (2017) 421-435.
[38] C. Apfel, J.R. Jahr, C.L. Kelly, et al., Effect of i.v. acetaminophen on total hip or knee replacement surgery: a case-matched evaluation of a national patient database, Am J Health Syst Pharm. 72(22) (2015) 1961-8.
[39] L. Xie, A.V. Joshi, D. Schaaf, et al., Differences in healthcare utilization and associated costs between patients prescribed vs. nonprescribed opioids during an inpatient or emergency department visit, Pain Pract. 14(5) (2014) 446-56.
[40] C.M. Duncan, K. Hall Long, D.O. Warner, et al., The economic implications of a multimodal analgesic regimen for patients undergoing major orthopedic surgery: a comparative study of direct costs, Reg Anesth Pain Med. 34(4) (2009) 301-7.
[41] L.S. Gold, S.A. Strassels, R.N. Hansen, Health Care Costs and Utilization in Patients Receiving Prescriptions for Long-acting Opioids for Acute Postsurgical Pain, Clin J Pain. 32(9) (2016) 747-54.
[42] T.J. Gan, S.B. Robinson, G.M. Oderda, et al., Impact of postsurgical opioid use and ileus on economic outcomes in gastrointestinal surgeries, Curr Med Res Opin. 31(4) (2015) 677-86.
[43] J.T. Santoso, M.A. Ulm, P.W. Jennings, et al., Multimodal pain control is associated with reduced hospital stay following open abdominal hysterectomy, Eur J Obstet Gynecol Reprod Biol. 183 (2014) 48-51.
[44] R.N. Hansen, A.T. Pham, B. Lovelace, et al., Comparative Analysis of Inpatient Costs for Obstetrics and Gynecology Surgery Patients Treated With IV Acetaminophen and IV Opioids Versus IV Opioid-only Analgesia for Postoperative Pain, Ann Pharmacother. 51(10) (2017) 834-839.
[45] A. Buvanendran, Opioid-free Anesthesia Results in Reduced Post-operative Opioid Consumption, edition, J Clin Anesth Pain Med. 2017;2(1):1-3, 2017.
[46] M. Bakan, T. Umutoglu, U. Topuz, et al., Opioid-free total intravenous anesthesia with propofol, dexmedetomidine and lidocaine infusions for laparoscopic cholecystectomy: a prospective, randomized, double-blinded study, Braz J Anesthesiol. 65(3) (2015) 191-9.
[47] J.P. Mulier, R. Wouters, B. Dilleman, et al., A Randomized Controlled, Double-Blind Trial Evaluating the Effect of Opioid-Free Versus Opioid General Anaesthesia on Postoperative Pain and Discomfort Measured by the QoR-40, Journal of Clinical Anesthesia and Pain Medicine. 2(1) (2018) 1-6.
[48] P. Ziemann-Gimmel, A.A. Goldfarb, J. Koppman, et al., Opioid-free total intravenous anaesthesia reduces postoperative nausea and vomiting in bariatric surgery beyond triple prophylaxis, Br J Anaesth. 112(5) (2014) 906-11.
[49] S. Tripathy, S. Rath, S. Agrawal, et al., Opioid-free anesthesia for breast cancer surgery: An observational study, J Anaesthesiol Clin Pharmacol. 34(1) (2018) 35-40.
[50] A.C. De Windt, K. Asehnoune, A. Roquilly, et al., An opioid-free anaesthetic using nerve blocks enhances rapid recovery after minor hand surgery in children, Eur J Anaesthesiol. 27(6) (2010) 521-5.
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Authors
Nassif, G. J., & Miller, T. E. (2019). Evolving the Management of Acute Perioperative Pain Towards Opioid Free Protocols: A Narrative Review. Journal of Current Medical Research and Opinion, 2(07), 203–212. https://doi.org/10.15520/jcmro.v2i04.130
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