Postsurgical Opioids Not Linked to Decreased Pain Intensity

A systematic review and meta-analysis found that opioid prescribing at surgical discharge increased adverse event risk and did not decrease pain intensity. These findings were published in The Lancet.

Investigators with McGill University in Canada searched publication databases through July 2021 for randomized controlled trials of opioid and opioid-free regimens after surgical discharge. A total of 47 trials were included in this review.

The study population in this analysis comprised 6607 individuals, among whom 59% were women. The average age was 21 to 63 years and the median follow-up duration was 7 days.

The studies involved dental (n=14), orthopedic (n=5), general (n=5), head and neck (n=5), orthopedic or plastic (n=3), plastic (n=2), orthopedic or neuro (n=1), and eye (n=1) surgeries. The nonopioid treatments typically comprised nonsteroidal anti-inflammatory drugs or acetaminophen. The opioid regimens typically comprised codeine, hydrocodone, and tramadol. The median oral morphine equivalent dose was 27 mg/day.

There was no evidence to support the use of opioids to decrease pain intensity at postoperative days 0 (weighted mean difference [WMD], -0.25; 95% CI, -0.74 to 0.24), 1 (WMD, 0.01; 95% CI, -0.26 to 0.27), 2 (WMD, 0.01; 95% CI, -0.26 to 0.28), 4 to 7 (WMD, 0.23; 95% CI, -0.01 to 0.47), or 8 to 30 (WMD, 0.33; 95% CI, -0.32 to 0.99). There was evidence to support increased pain intensity among opioid recipients at postoperative day 3 (WMD, 0.44; 95% CI, 0.18-0.70) and pain interference during the first week after discharge (WMD, 3.51; 95% CI, 1.01-6.02).

Opioids were associated with increased risk for overall nonspecific adverse events (risk ratio [RR], 1.78; 95% CI, 1.20-2.66), nausea (RR, 2.37; 95% CI, 1.59-3.55), dizziness (RR, 2.22; 95% CI, 1.20-4.08), constipation (RR, 1.63; 95% CI, 1.04-2.57), and drowsiness (RR, 1.57; 95% CI, 1.02-2.42).

Postdischarge opioids did not associate with the quality of recovery at day 2 (WMD, -0.34; 95% CI, -0.87 to 0.19), improved patient disposition (RR, 2.05; 95% CI, 0.95-4.42), patient dissatisfaction (RR, 1.14; 95% CI, 0.67-1.94), or health care reutilization (RR, 0.88; 95% CI, 0.30-2.61).

The major limitation of this analysis was that heterogeneity was greater than 50% for the primary outcomes.

This study did not support the use of opioids for postsurgical analgesia, the researchers noted, as it did not associate with decreased pain intensity or improved outcomes but did increase risk for adverse events. “Although our findings support that clinicians should consider excluding opioids from discharge prescriptions in many surgical settings, there is a great need to advance the quality and scope of research to support evidence-based pain management and mitigate opioid-related harms after surgery,” they concluded.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Giore JF Jr, El-Kefraoui C, Chay M-A, et al. Opioid versus opioid-free analgesia after surgical discharge: a systematic review and meta-analysis of randomised trials. Lancet. 2022;399(10343):2280-2293. doi:10.1016/S0140-6736(22)00582-7