Optimal Strategies for Opioid Weaning After Ambulatory Surgery

Each year in the United States, more than 100 million people undergo surgical procedures, including 53 million performed in the ambulatory setting. Findings suggest that nearly all of these patients will receive a postoperative opioid prescription, and 1 study found continued use in 7.7% of opioid-naive patients 1 year after surgery.¹

Other results have linked the prescription of opioids after short-stay surgery to a 44% greater risk for prolonged opioid use.² “While judicious management of opioids is warranted in all patients, the current growing opioid epidemic warrants meticulous weaning of pain medications post-operatively,” wrote the authors of a review published in Current Pain and Headache Reports.³ “In the ambulatory surgery settings, such direction is very necessary given limited immediate post-operative follow-up for patients being discharged from the hospital.”

The number of ambulatory surgeries has increased worldwide in recent decades, and 25% to 65% of patients undergoing these procedures experience moderate to severe pain after discharge. However, postoperative opioid weaning, especially after ambulatory surgery, is not adequately addressed in research or professional guidelines.

Key points from the current review in which studies pertaining to this topic were examined are highlighted here.

• A cohort study involving 107 ambulatory surgery patients identified several preoperative factors as being associated with prolonged postsurgical pain, including depression, patient report of prescribed or illicit opioid use, and self-perceived addiction susceptibility.⁴
• In individuals who chronically consume opioids before surgery, postoperative opioid use was found to be up to 3-fold higher compared with in opioid-naive patients.⁵ A method that may effectively wean these patients off off opioids may be achieved by converting the “daily intravenous opioid dose into an oral-dose equivalent and to administer one-half to two-thirds of this dose in the form of a long-acting opioid [and the remainder] as a short-acting formulation as needed,” as explained in the review. “By providing medication for both post-operative basal and breakthrough pain, [it is proposed] that patients and providers can slowly titrate the short-acting amount as surgical pain subsides.”
• It is well-established that the use of adjunctive analgesics, including nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen, facilitates postsurgical pain control during opioid weaning both in individuals with chronic pain and in opioid-naive patients. These medications have been found to reduce postoperative opioid requirements and pain scores.
• The current standard of care for perioperative analgesia is a multimodal approach that combines “lower doses of opioids with non-opioid agents such as NSAIDs, selective COX2 inhibitors, acetaminophen, glucocorticoids, and gabapentinoids, and frequently employ[s] the intraoperative use of local anesthetics for peripheral nerve blocks and for skin infiltration just prior to incision and at wound closure,” the authors wrote.^[3] This approach “makes use of the distinctive yet synergistic physiological mechanisms of action of these agents, thus reducing the need for opioid administration.”
• In addition, this strategy reduces the risk for postoperative nausea and the amount of opioids needed postdischarge. For example, multiple studies have shown that NSAIDs combined with propofol and nitrous oxide anesthesia reduced postoperative pain and opioid requirement, and randomized controlled trials indicate that selective COX-2 inhibitors reduce the need for postoperative opioids.³
• One such model that is increasingly used in the ambulatory setting is Enhanced Recovery After Surgery (ERAS), which emphasizes multimodal analgesia and a focus on early mobilization and resumption of oral intake. In research published in 2015, implementation of ERAS was found to reduce care time by more than 30% and postsurgical complications by up to 50%.⁶
• Another multimodal approach, the perioperative surgical home model, has been shown to reduce the rate of readmissions and the risk for conversion from acute to chronic pain while improving patient satisfaction.⁷ This model involves the early identification of patients with a high risk for chronic postoperative pain and, if indicated, preoperative and postoperative consultation with a multidisciplinary team that may include anesthesiologists, psychologists, and nurse practitioners. A 2-year study of 343 patients treated with this model found reductions in pain, anxiety, and opioid use.⁸
• Regional anesthesia has also been linked to faster discharge and superior analgesia compared with general anesthesia in outpatient surgery patients.³

The “weaning of pain medications in ambulatory surgery settings requires teams that are adept at treating varied patient populations through tailored, novel means that invoke multimodal analgesia,” the authors of a review published in Current Pain and Headache Reports concluded. “Given the growth of surgeries moving toward the ambulatory sector, more data and practice guidelines are needed to direct postoperative pain regimen titration for these patients.”^[3]

Clinical Pain Advisor talked with review coauthor Brandon I. Roth, MD, a resident physician in the department of anesthesiology at Yale-New Haven Hospital, for additional thoughts on these findings.

Clinical Pain Advisor: What are the main takeaways from your review?

Dr Roth: There is very little evidence outlined in the current literature regarding the management and discontinuation of postoperative pain medications in the ambulatory setting. In our review, we highlight strategies that clinicians may implement in order to [improve outcomes for] ambulatory surgery patients.

Clinical Pain Advisor: What are the treatment implications for clinicians?

Dr Roth: Retrospective and patient-reported studies suggest our approach should be similar to acute pain management strategies, including the identification of high-risk patients and development of an appropriate pain plan. The use of multimodal analgesia, regional anesthesia, and implementing transitional pain services to manage postoperative pain, as well as the use of the perioperative surgical home, may all contribute to meeting these goals.

Clinical Pain Advisor: What should be the focus of future research on this topic?

Dr Roth: Notably, many medical facilities lack the ability and additional infrastructure to monitor postoperative recovery. More published research into applied models and their outcomes would be prudent in moving forward with a more refined, uniform approach to the management of patients in this setting.

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References

1. Jiang X, Orton M, Feng R, et al. Chronic opioid usage in surgical patients in a large academic center. Ann Surg. 2017; 265(4):722-727.
2. Alam A, Gomes T, Zheng H, Mamdani M, Juurlink D, Bell C. Long-term analgesic use after low-risk surgery: a retrospective cohort study.Arch Int Med. 2012;172(5):425-430.
3. Roth B, Boateng A, Berken A, Carlyle D, Vadivelu N. http:Post-operative weaning of opioids after ambulatory surgery: the importance of physician stewardship. Curr Pain Headache Rep. 2018;22(6):40.
4. Carroll IR, Hah JM, Barelka PL, et al. Pain duration and resolution following surgery: an inception cohort study. Pain Med. 2015;16(12):2386-2396.
5. Carroll IR, Angst MS, Clark JD. Management of perioperative pain in patients chronically consuming opioids. Reg Anesth Pain Med. 2004;29(6):576–591.
6. Lyass S, Link D, Grace B, Verbukh I. Enhanced recovery after surgery (ERAS) protocol for out-patient laparoscopic sleeve gastrectomy in ambulatory surgery center – safe and effective.Surg Obes Relat Dis. 2015;11(6):S198.
7. Vetter TR, Kain Z. Role of the perioperative surgical home in optimizing the perioperative use of opioids. Anesth Analg. 2017;125(5):1653-1657.
8. Azam MA, Weinrib AZ, Montbriand J, et al. Acceptance and commitment therapy to manage pain and opioid use after major surgery: preliminary outcomes from the Toronto general hospital transitional pain service. Can J Pain. 2017;1(1):137-149.