OnMedica – News – Poor Pain Management

More research is needed to help manage opioid tolerance

New studies show that the goals of eliminating pain after surgery have resulted in an increase in the use of opioids.

For the first time, a new series of three articles *, published The lancet, brings together global evidence detailing the role of surgery in the opioid crisis.

Each year, 320 million people undergo surgery and chronic pain occurs in 10% of cases.

It usually begins with acute postoperative pain that is difficult to control and evolves into persistent pain with characteristics that do not respond to opioids. In response to this pain, clinicians often prescribe higher opioid levels, but this may lead to opioid-induced tolerance and hyperalgesia, creating an increased pain cycle and increased use of opioids. Opioids where the pain remains poorly managed.

"Providing opioids to surgical patients poses a particularly difficult problem, forcing clinicians to balance the management of acute pain and minimize the risks of persistent opioid use after surgery," said Professor Paul Myles, head of the series at Monash University, Australia. "Over the last decade, strong opioids have been increasingly used to treat acute and chronic pain, which has been badociated with a growing epidemic of prescription opioid misuse, death and death. deaths related to overdose. To reduce the increased risk of misuse of opioids in operated patients, we call for a comprehensive approach to reduce opioid prescriptions, increase the use of alternative medications, reduce residual opioids at home and inform patients. patients and clinicians about the risks and benefits of opioids. "

The opioid crisis began in the United States in the mid-1990s and early 2000s, according to the authors, when insufficient pain relief was perceived as an indicator of poor quality of health care. Opioids are now one of the most prescribed drugs in the United States, with similar, though less marked, trends in other high-income countries, including the United Kingdom.

"From the mid-1990s, clinical guidelines and policies were created to eliminate pain and clinicians were encouraged to increase the number of opioid prescriptions. As a result, the use of prescription opioids worldwide has more than doubled between 2001 and 2013, from three billion to 7.3 billion daily doses per year. This increase is related to an increase in abuse and abuse in some countries, such as the United States, Canada, and Australia. and the UK, "says Dr. Brian Bateman, author of the series, Brigham and Women's Hospital, USA.

In the United States, the prescription of opioids for minor surgical procedures has increased (up to 75% of patients are prescribed opioids on discharge from the hospital) and the risk of developing opioids for minor surgical procedures has increased. Abuse increased by 44% every week and during new prescriptions after discharge.

In addition to being often ineffective in the treatment of chronic pain, opioid prescriptions after surgery have also been badociated with misuse and misuse of opioids, development of opioid disorders and overdose of opioids. opioids. Home storage of excess opioid medications is an important source of diversion. In one study, 61% of patients who had surgery had a drug overage, with 91% of them keeping their medications at home.

The authors advocate a comprehensive approach to reduce these risks, including transient pain treatment clinics, opioid elimination options for patients (such as secure recovery boxes and medication management) to to reduce home-stored opioids and the risk of diversion, and options for non-opioid and opioid pain relief.

"Ultimately, chronic pain after surgery requires a complete biopsychosocial approach to treatment. Transition pain clinics are a new approach to reduce fracture and eliminate over-prescription opioids after surgery. These clinics could help identify people at risk for chronic pain after surgery and offer additional visits, treatment, referral to alternative services, such as rehabilitation, addiction, mental health and chronic pain. . Together, this could help reduce the consumption and abuse of opioids, "says Professor Myles.

Clinical guidelines and policies must also establish a consensus for opioid prescribing after surgery, thus providing clinicians with default and maximum prescribing levels, the authors say.

According to them, additional research is also needed to effectively manage opioid tolerance and opioid-induced hyperalgesia.

"A better understanding of the effects of opioids at the neurobiological, clinical and societal levels is needed to improve future care for patients," says Professor Lesley Colvin, author of the series, at the University of Dundee, UK . "There are gaps in research that need to be addressed to improve the current situation of opioids. First, we need to better understand opioid tolerance and opioid-induced hyperalgesia to develop pain relief treatments that work under these conditions. We also need in-depth studies of the population to better understand the connection between opioid use during surgery and chronic pain, as well as what predisposes some people to the misuse of drugs. opioids to provide alternative pain relief during surgery. These recommendations affect many areas of the opioid crisis and could also benefit the wider crisis. "

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* Series of three articles:

1. Glare P, Aubrey KR, Myles PA. Transition from acute pain to chronic pain after surgery. The lancet. Posted: 13th April 2019. DOI: 10.1016 / S0140-6736 (19) 30352-6

2. Neuman MD, BT Bateman, Wunsch H. Inappropriate prescribing of opioids after surgery. The lancet. Posted: 13th April 2019. DOI: 10.1016 / S0140-6736 (19) 30428-3

3. Colvin LA, Bull F, TG Hales. Perioperative opioid badgesia: when is it enough? Examination of opioid-induced tolerance and hyperalgesia. The lancet. 13 April 2019. DOI: doi.org/10.1016/S0140-6736 (19) 30430-1