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The goals of eliminating pain after surgery have resulted in an increase in the use of opioids and are a major cause of the opioid crisis in the United States, Canada and Canada. ;other countries. For the first time, a new series of three articles, published in The Lancet, brings together global evidence detailing the role of surgery in the opioid crisis.
Chronic postoperative pain is a growing problem as the population ages and more surgeries are performed. This can happen after any type of surgery. 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 can lead to opioid-induced tolerance and hyperalgesia (increased counter-intuitive pain caused by increased consumption of opioids). 39; opioids), thus creating an increased pain cycle and increased use of opioids where pain remains poorly managed.
"Providing opioids to operated patients poses a particularly difficult problem, forcing clinicians to balance the management of acute pain and to minimize the risks of persistent opioid use after surgery," said Professor Paul Myles, head of the series at Monash University, Australia. "Over the past 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, and death. Overdose-Related Reduce the increased risk of opioid misuse for operated patients, we call for a comprehensive approach to reduce opioid prescriptions, increase the use of alternative medications, reduce opioids stay home and inform patients and clinicians about the risks and benefits of opioids. " [1]
Risks badociated with prescription opioids
The opioid crisis began in the United States in the mid-1990s and early 2000s, when inadequate pain relief was considered 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. In comparison, many low-income countries around the world have little access to opioids and can not provide adequate pain relief – as reported in the Lancet Commission on Global Access to Palliative Care and Relief. pain [2].
"Starting in the mid-1990s, clinical guidelines and policies were created with the goal of eliminating pain, and clinicians were encouraged to increase the number of opioid prescriptions. Use of prescribed opioids more than doubled between 2001 and 2013, from 3 billion to 7.3 billion daily doses per year, which has been badociated with an increase in abuse and abuse in some countries, such as the United States, Canada, Australia and the United Kingdom. "says Dr. Brian Bateman, author of the series, Brigham and Women's Hospital, USA. [1]
Currently, opioids are often the best pain relief available to manage acute pain. In surgery, the administration of opioids reduces the necessary dose of general anesthetic and opioids appropriate and appropriate after surgery improve the comfort of the patient. However, the persistent use of opioids after surgery may predispose patients to long-term use of opioids. In addition, misuse must be considered on an ongoing basis. 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.
An American study involving more than 155,000 patients with one of four low-risk surgeries (carpal tunnel repair, knee arthroscopy, keyhole surgery for gallbladder removal or surgery of the keyhole for inguinal hernia repair) showed that prescription opioids for everyone increased from 2004 to 2012, and that the average daily opioid dose prescribed for postoperative pain also increased by 13% (30 milligrams of morphine equivalent [MME]) for all procedures on average, with increases ranging from 8% (17 MME) for patients undergoing an 18% inguinal hernia repair (45 MME) for patients undergoing knee arthroscopy (see figure in paper 2).
There are also marked international differences in the prescription of opioids after surgery. Data comparing a US hospital and a Dutch showed that 77% of patients undergoing a hip fracture repair at the US hospital had received opioids, none in a Dutch hospital and 82% of patients Americans who received opioids after ankle fracture, compared to 6% of Dutch patients. Despite these differences, patients in each of these countries have similar levels of satisfaction with the management of pain.
In addition, excessive amounts of opioids are prescribed to American patients after surgery. Studies conducted between 2011 and 2017 found that 67 to 92% of American operated patients reported not using all of their opioid tablets, generally leaving 42 to 71% of their unused prescribed pills.
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.
Reduce the risks of opioids and improve the management of postoperative chronic pain
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. Additional research is also needed to effectively manage opioid tolerance and opioid-induced hyperalgesia.
"Ultimately, chronic pain after surgery requires a complete biopsychosocial approach to treatment.Transient pain clinics provide a new approach to reduce the gap, in order to eliminate the overestimation of pain." opioids after surgery These clinics could help identify people at risk for chronic pain after surgery, and offer additional visits to the clinic, review treatment, refer the patient to alternative services, such as rehabilitation, addiction , Mental Health Services and Chronic Pain Treatment Services Together, this could help reduce opiate abuse and abuse, says Professor Myles. [1]
Clinical guidelines and policies must also establish a consensus for prescribing opioids after surgery, offering clinicians default and maximum prescribing levels. For example, there is currently no guide as to how long patients should remain on opioids. In the United States, a study was developed to recommend various surgeries (based on patient surveys and prescription replacement data) – 4 to 9 day postoperative opioid recommendations for surgical procedures general, 4 to 13 days for women's health procedures and 6-15 days for musculoskeletal procedures. In addition, a study that adapted the default number of opioid pills prescribed from 30 to 12 showed a marked decrease in the number of pills administered after 10 common surgical procedures.
"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 in order to develop treatment-based relief therapies. the pain that work under these conditions.to better understand the connection between opioid use during surgery and chronic pain, and we must understand what predisposes some people to opioid abuse in order to be able to offer an alternative pain relief during surgery to these patients.These recommendations touch on many areas of the opioid crisis and could: benefit the wider crisis too. " [1]
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NOTES TO EDITORS
This study was funded in part by a practitioner's grant from the Australian National Board of Health and Medical Research, the Pain Management Research Institute, the National Institute on Drug Abuse and the Canadian Institutes of Health Research. It was led by researchers from the Pain Management Research Institute, the University of Sydney, the Kolling Institute, the Royal North Shore Hospital, the Alfred Hospital, the Brigham and Women's Hospital and from the Harvard Medical School, Sunnybrook Health Sciences Center, Sunnybrook Research Institute, the University of Toronto and the University of Toronto. Dundee, Ninewells Hospital and Medical School.
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