Best practice in managing postoperative pain

Controlling acute pain after surgery is important not only in the immediate postoperative phase but also to prevent chronic postsurgical pain, which can develop in as many as 10% of patients. A Series of three papers in this week's issue examines postoperative pain management, outlines how and why acute pain can become chronic, what can be done to lessen that risk, and the role of opioids. In many countries, opioid misuse is escalating, causing thousands of deaths annually. As the Series explores, excessive prescribing of opioids for pain control after surgery is now recognised as an important driver of opioid misuse and related harm. For many, “opioid dependency started with a prescription after minor trauma or surgery”, as Markus Hollmann and colleagues outline in a Comment. Dependency often results in patients requesting repeat prescriptions or buying more opioids online or on the street. Despite attempts to prevent the illegal sale of opioids, online sales are rising in the USA—for example, with the availability of tramadol being a particular problem. Improvements in perioperative prescribing and a reduction in opioids on and after discharge are needed to have a tangible effect on the opioid epidemic. Some US states, for example, impose limits on how many pills physicians can prescribe per day, and others make continuing medical education a requirement for physicians prescribing controlled substances. The Centers for Medicare and Medicaid Services require consultation between pharmacists and prescribers about high morphine doses in daily prescriptions for many chronic pain patients. Pain is a highly personal and subjective experience, which is increasingly recognised to be shaped by life events, mood, fear, anxiety, and anticipation, among other influences. Management of postoperative pain is best tailored to the individual, with multimodal non-opioid analgesics used first. Local anaesthesia might have a role, followed by careful prescription of tapering doses of opioids, if needed. Moreover, communication between hospital and primary care needs to improve to ensure opioid prescribing is carefully managed in the community. Optimal postoperative pain management: redefining the role for opioidsFear of pain is deeply rooted among patients who are about to have surgery.1 Satisfactory perioperative pain management is crucial to assuring a good patient experience, optimising postoperative outcomes, and enhancing functional recovery after surgery.2 Despite decades of research showing the benefits of various new analgesic strategies, many patients endure severe postoperative pain,3 and this holds true across all age groups and continents, even after surgery widely considered to be minor.4 A 2016 study from the USA, which enrolled 799 449 patients, showed that reliance on opioid analgesics as the mainstay for perioperative pain management is still widespread. Full-Text PDF Transition from acute to chronic pain after surgeryOver the past decade there has been an increasing reliance on strong opioids to treat acute and chronic pain, which has been associated with a rising epidemic of prescription opioid misuse, abuse, and overdose-related deaths. Deaths from prescription opioids have more than quadrupled in the USA since 1999, and this pattern is now occurring globally. Inappropriate opioid prescribing after surgery, particularly after discharge, is a major cause of this problem. Chronic postsurgical pain, occurring in approximately 10% of patients who have surgery, typically begins as acute postoperative pain that is difficult to control, but soon transitions into a persistent pain condition with neuropathic features that are unresponsive to opioids. Full-Text PDF Inappropriate opioid prescription after surgeryWorldwide, the use of prescription opioid analgesics more than doubled between 2001 and 2013, with several countries, including the USA, Canada, and Australia, experiencing epidemics of opioid misuse and abuse over this period. In this context, excessive prescribing of opioids for pain treatment after surgery has been recognised as an important concern for public health and a potential contributor to patterns of opioid misuse and related harm. In the second paper in this Series we review the evolution of prescription opioid use for pain treatment after surgery in the USA, Canada, and other countries. Full-Text PDF Perioperative opioid analgesia—when is enough too much? A review of opioid-induced tolerance and hyperalgesiaOpioids are a mainstay of acute pain management but can have many adverse effects, contributing to problematic long-term use. Opioid tolerance (increased dose needed for analgesia) and opioid-induced hyperalgesia (paradoxical increase in pain with opioid administration) can contribute to both poorly controlled pain and dose escalation. Hyperalgesia is particularly problematic as further opioid prescribing is largely futile. The mechanisms of opioid tolerance and hyperalgesia are complex, involving μ opioid receptor signalling pathways that offer opportunities for novel analgesic alternatives. Full-Text PDF