The opioid crisis, in which addiction and harm are related to pain-relieving opioid drugs, has been well documented. It has been concentrated in the USA but is now affecting most Western nations and increasingly, developing countries also. In some cases, this addiction and subsequent harm begins when the patient is given these drugs for pain relief after surgery.

To help confront this, an international group of global experts including anaesthetists, surgeons and other healthcare professionals have come together to publish a consensus statement on the prevention of opioid-related harm in adult surgical patients. The consensus statement is published in Anaesthesia (a journal of the Association of Anaesthetists).

“Opioids are effective medicines that form an integral component of balanced multimodal painkilling strategies for the management of acute pain in postoperative patients,” explain the statement co-authors, who include Professor Dileep Lobo, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK. “However, over the past decade it has been increasingly appreciated that, in efforts to improve pain relief after surgery, doctors prescribing these drugs to help pain relief during and after surgery have unwittingly contributed to persistent postoperative opioid use, abuse and harm in some patients.”

They add: “In addition to the social and economic costs of opioid misuse, there are personal costs, with many people dying from opioid overdose, or in accidents caused, for example, by driving under the influence of opioids.”

Ways to reduce possible harm begin before surgery, since the strongest predictor of persistent postoperative opioid use post-surgery is pre-existing chronic opioid use. The incidence of persistent postoperative opioid use can be up to 10 times higher in those taking opioids long- term before surgery than in patients who have never used opioids.

The main points from the consensus statement are:

• All patients undergoing surgery should be assumed to be at risk of developing persistent postoperative opioid use/addiction and may need interventions to mitigate those risks. However, some patients are at particularly high-risk of opioid related respiratory impairment, including older patients; those with sleep-disordered breathing; obesity; kidney disease; respiratory, cardiac and neurological diseases; diabetes; tolerance to opioids; and genetic variations in opioid metabolism.
• Healthcare teams must consider optimising management of pre-operative pain and psychological risk-factors before surgery, including weaning patients off opioids they are already taking where possible. They should ensure realistic expectations of postoperative pain control, both in hospital and after discharge.
• Provision of opioid painkillers should be guided by functional outcomes, rather than just a rating of the patient’s pain using existing scales.
• Multiple methods of pain management should be optimised, and patients educated about the use of non-pharmacological and non-opioid painkilling strategies to reduce the amount and duration of opioids required to restore function

• Long-acting opioids should not be used routinely for acute postoperative pain. (e.g. modified-release oxycodone, transdermal fentanyl patches)
• A patient-centred approach should be used to limit the number of tablets and the duration of usual discharge opioid prescriptions, typically to less than a week. (Post-discharge prescriptions of opioids, if necessary, should be limited to less than a week’s duration. A small number of patients may need repeat prescriptions, but these should not be automatic. GPs should see patients and assess them before re-prescribing opioids).
• Automated post-discharge repeat prescriptions for opioids should be avoided. Doctors, including those in outpatient clinics and general practice, should perform a patient review if more opioids are requested. Research has shown each additional repeat prescription has been found to increase the risk of opioid misuse (encompassing diagnoses of opioid dependence; abuse; or overdose) by 40%, with each additional week of opioids taken raising the risk of misuse by 20%. (A small number of patients may need repeat prescriptions, but these should not be automatic. GPs should see patients and assess them before re-prescribing opioids).
• Patients should be advised on safe storage and disposal of unused opioids and directed to avoid opioid diversion to other individuals (e.g. sharing with friends and family). Addiction surveys have shown that around 50% of adults who misuse opioids obtain them from friends and family. This also avoids accidental deaths. Paediatric mortality from unintentional opioid overdose has increased three-fold in the last 20 years and has followed a similar time trend to adult overdose deaths

The authors also highlight the dangers of driving under the influence of opioids, that can impair driving skills and cognitive reasoning in a similar manner to alcohol. “Driving under the influence of drugs, including prescribed opioids, is now recognised to be a major cause of motor vehicle collisions and subsequent fatalities, particularly if the person commenced the opioid within the previous 30 days,” explain the authors, who add that many countries have established laws making driving under the influence of opioids illegal.

They conclude: “While the use of opioids during and after surgery has the capacity to promote recovery after life-saving or life-enhancing surgery, their use can be associated with harm from persistent postoperative opioid use; opioid-induced respiratory impairment; opioid diversion to people they were not originally prescribed for; and driving under the influence of prescription opioids. Strict control of opioid use within hospitals (stewardship) is required to minimise the risk of opioid-related harm. This will require the multidisciplinary involvement of anaesthetists; surgeons; pain specialists; pharmacists; nursing staff; physiotherapists; primary care clinicians; hospital management; and patients to adopt the recommendations from this consensus statement to local practice.”

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Professor Dileep Lobo, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen’s Medical Centre, Nottingham, UK. +44-7545966471) dileep.lobo@nottingham.ac.uk

Co-author Dr Kariem El-Boghdadly, Consultant Anaesthetist, Guy’s and St Thomas’ NHS Foundation Trust, London, UK. Please e-mail first to arrange interview. T) +44 7958 904883 E) editor-kariem@anaesthetists.org

Co-author and expert on pain medicine and addiction: Dr Jane Quinlan, Oxford University Hospitals NHS Foundation Trust, Oxford, UK. T) +44 7545 995 615 E) jane.quinlan@ouh.nhs.uk