Sage Journals: Discover world-class research

Abstract

Excellent resources are now available that distil the best evidence around opioid prescribing in the perioperative period, including the list of recommendations provided by the international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. While some of the recommendations have been widely accepted as an essential part of postoperative practice, others have had slow and variable adoption. This article focuses on the items where theory and practice still diverge and suggests how best to close that gap. We must also remain mindful that while education is essential, it is on the lowest rung of implementation efficacy and, on its own, is a poor driver of behaviour change. Ongoing structural nudges and the use of local procedure-specific analgesic pathways will also be helpful in addressing the gap between evidence-based recommendations and practice.

Keywords

Anaesthesia pain management perioperative anaesthesia pharmacology opioid surgery

Introduction

Excellent resources are now available that distil the best evidence around opioid prescribing in the perioperative period. One such resource is the list of recommendations provided by the international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients.¹ While some of the recommendations, for example regular sedation assessment, have been widely accepted as an essential part of postoperative practice, others have had slow and variable adoption. This article focuses on the items where theory and practice still diverge and suggests how best to close that gap.

Recommendations for best clinical practice

The following list of recommendations has been reproduced from the multidisciplinary consensus statement of Levy et al.:¹

All patients undergoing surgery should be assumed to be at risk of developing persistent postoperative opioid use and opioid-induced ventilatory impairment and may need interventions to mitigate those risks.

Consider optimising management of preoperative pain and psychological risk factors before surgery, including weaning of opioids when possible. Ensure realistic expectations of postoperative pain control, both in hospital and after discharge.

Provision of opioid analgesia should be guided by functional outcomes, rather than unidimensional pain scores alone.

Multimodal analgesia should be optimised and patients educated about the use of non-pharmacological and non-opioid analgesia to reduce the amount and duration of opioids required to restore function.

Long-acting opioids should not be used routinely for acute postoperative pain.

A patient-centred approach should be used to limit the number of tablets and the duration of usual discharge opioid prescriptions, typically to less than a week.

Automated post-discharge repeat prescriptions for opioids should be avoided. Perform a patient review if more opioids are requested.

Hospitals should have strategies to mitigate the occurrence of opioid-induced ventilatory impairment. Specifically, all inpatients receiving postoperative opioids must have their level of sedation assessed at appropriate and repeated intervals.

Modifiable factors that have been identified as increasing the risk of opioid-induced ventilatory impairment and persistent postoperative opioid use should be addressed. These factors include medicines with sedative properties; long-acting opioids; and reliance on unidimensional pain scores alone to guide prescribing and titration.

Patients should be advised on safe storage and disposal of unused opioids and directed to avoid opioid diversion to other individuals (e.g. sharing with friends and family).

How do we implement the most modifiable points in the recent statement?

Items 1 and 2: preoperative communication and planning

The preoperative consultation, even when online, remains a key opportunity for conversations around expectation setting, anxiety modification, formulation and discussion of the analgesic plan including considering non-drug techniques and requirements for postoperative opioid weaning.

The preoperative consult provides an opportunity to identify those patients who will require modification of usual analgesic care to help avoid persistent postoperative opioid use, increased opioid-related adverse effects and worse outcomes. This does not need to involve collecting more information than is usual preoperatively, but does involve gathering the relevant parts of the patient history into a category of analgesia-related factors in the same way we might assess for modifiable cardiovascular or respiratory factors. Relevant flags would include a presentation for painful surgery such as thoracotomy or upper abdominal laparotomy, especially if younger and female, and those on preoperative opioids. Special attention should be paid if these factors exist in combination with other risk factors for poor satisfaction with analgesia such as psychiatric comorbidities (particularly anxiety and catastrophisation) or dependence on any substance, prescribed or otherwise.² If a patient is identified as being likely to have poor analgesia, then the recommended analgesic plan should be discussed with the patient with a view to helping them understand risks and how they will be mitigated, with shared decision-making being the goal.

A further opportunity to identify those who require modification of analgesic approach occurs with patients whose pain scores remain persistently high in the first week postoperatively; that is, a trajectory of pain scores that is flat or even increasing.³ The trajectory of pain scores is important because the slope of the downward pain trajectory seems to be a better predictor of low pain at three and six months, compared to the magnitude of the initial pain scores.^4,5 Postoperatively a flat or upward pain trajectory should trigger readjustment of analgesia in line with the recommendations for opioid-tolerant patients (as detailed below) rather than the addition of slow-release (SR) or an additional opioid.

The largest and most consistent risk factor for persistent postoperative opioid use is preoperative opioid use.⁶ In particular, preoperative oxycodone use seems to be associated with higher persistent postoperative use when compared with other opioids.⁷ In Australia the highest rates of preoperative opioid use are in patients presenting for joint replacement and spinal surgery,⁸ with a twofold higher rate for patients treated in non–capital city hospitals compared with capital city hospitals (Liu et al., submitted to Anaesthesia and Intensive Care).

It is therefore particularly important that those who work in non–capital city hospitals engage with surgeons and general practitioners (GPs) in order to modify the highest risk factor for persistent opioid use. Recommendations for preoperative analgesic regimens should align with GPs' evidence-based prescribing for patients awaiting spinal and joint replacement surgery. Furthermore, communication at the time of booking between surgeons, patients and their GPs provides an additional opportunity to reinforce messages about the lack of efficacy of opioids in the management of chronic non-cancer pain and the potential benefits of dose reduction preoperatively when treatment is already established.⁹

Preoperative opioid use, especially with an oral morphine equivalent over 60 mg per day (this is equivalent to 40 mg oxycodone per day), is a known risk factor for worse postoperative analgesia and postoperative complications including increased risk of infection, increased length of stay and a threefold increase in opioid-induced ventilatory impairment.¹⁰ Despite this; there have been few studies published on any changes in these outcomes with preoperative weaning.¹¹ The limited evidence that exists has found positive benefits.¹²

If preoperative weaning is contemplated, it should be slow and voluntary rather than forced. Any decrease in opioid dose must be well supported by the patient’s primary care providers.¹³ Patients and clinicians should be encouraged and reassured that substantial evidence demonstrates that voluntary weaning does not worsen, and may improve, pain scores and may significantly improve the effectiveness of postoperative analgesia.^14,15 Modifiable psychosocial risk factors that are more common in those patients taking opioid and sedative drug combinations may be addressed through services such as psychology or multidisciplinary pain services.

Item 4: optimise multimodal analgesia. What does this mean now?

Multimodal analgesia has changed substantially over the past 20 years. Understanding how it has changed allows us to optimise its opioid-sparing function.

Maximise simple analgesic use

Parecoxib and celecoxib have excellent safety profiles outside of cardiac surgery and a longer duration of action when compared to traditional non-specific non-steroidal anti-inflammatory drugs (NSAIDs). The lack of increased bleeding risk with these drugs allows expansion of their use to surgery with a high risk of bleeding. Celecoxib also exhibits reduced thrombotic, renal and hypertensive effects compared with the commonly used alternative, ibuprofen.^16,17

Increasingly there is greater acceptance of the use of carefully selected NSAIDs in the well elderly population, even in those with very advanced age. For patients with a borderline risk assessment, the clear dose–response profile of adverse events for celecoxib means that a single morning 100 mg dose can be administered to help maximise the patient’s capacity to engage and participate in activities which promote recovery. A single daily dose minimises the risk of gastrointestinal and thrombotic complications, maximising the pool of patients eligible for NSAIDs.¹⁷

Paracetamol is available as an intravenous formulation, and therefore remains a valuable part of a multimodal formulary even for patients who are unable to take oral medications. Paracetamol in combination with NSAIDs has been demonstrated to be more effective than either drug alone;^18,19 however, the clinical effect size may not be large.

Dexamethasone extended applications

Dexamethasone has been used as an analgesic for many years in dental and maxillofacial surgery and has excellent efficacy in reducing pain in tonsillectomy.²⁰ Its analgesic efficacy has also been demonstrated more recently in orthopaedic and spinal procedures with no evidence of increased risk of infection.^21,22 The analgesic requirement for these procedures occurs primarily in the first 24 hours postoperatively, and importantly dexamethasone can also contribute to a decrease in nausea, vomiting and fatigue, and to an overall improved quality of recovery.^23,24

Regional blocks and local anaesthetic catheter techniques as background analgesia

Provision of regional/local anaesthesia has significantly improved in recent years. Ultrasound contributes significantly to improving block success rates. The use of a programmed intermittent bolus technique can increase thoracic block spread and improves epidural analgesia,^25–27 but evidence of a major benefit for peripheral catheter programmed intermittent bolus is still lacking.^28,29

Gabapentinoids

Pregabalin and gabapentin may offer minor reductions in opioid use and pain scores in procedures that are known to be particularly painful;^30,31 however, this may come at the expense of an increased rate of somnolence, sedation and respiratory depression when combined with opioids. If other non-sedating agents, such as anti-inflammatories, dexamethasone, or local anaesthesia cannot be used, or provide inadequate analgesia, gabapentinoids may be useful adjuncts in the context of acute neuropathic pain states.³²

Infusions

Lidocaine and other infusions may be used for those patients in whom minimising opioids is crucial (bariatric patients) or those with chronic pain or high preoperative opioid use. Lidocaine has evidence of safety in patients with normal hepatic, renal and cardiac function. Evidence of benefit is limited by the small number, size and lack of homogeneity of studies; however, there is some evidence for use when delivered as an infusion for visceral surgery and acute neuropathic pain.^33,34 Intraoperative dexmedetomidine has been used but safety concerns remain,^35,36 while ketamine intra- and postoperatively can be a useful adjunct particularly for major spinal surgery and for those patients who are hyperalgesic secondary to chronic opioid use or chronic pain.^37,38

Choice of opioid type and dose

If a stated aim of opioid-sparing analgesia is to reduce the burden of opioid-induced side-effects, then a strong argument can be made for choosing an opioid that is less likely to be associated with side-effects. Multiple studies have demonstrated reduced constipation and respiratory depression with tapentadol immediate-release (IR) compared with oxycodone IR at equiefficacious doses.^39,40 There is also evidence of substantially lower morbidity or mortality requiring ambulance attendance with the use of tapentadol in the community in comparison to codeine, oxycodone and tramadol.⁴¹ This is important when considering early post-surgery discharge when patients will still likely require opioid analgesia.

Other atypical opioids such as tramadol and buprenorphine have also been demonstrated to have a reduced side-effect profile and lower risk of diversion and abuse compared to pure mu-agonists such as oxycodone.⁴² Sublingual buprenorphine IR can be particularly useful in the patient who is not able to tolerate or predictably absorb oral tablets.

The use of IR opioid allows for the wide variability in opioid requirements between patients and for patient-led titration and weaning of opioid dose, but it is important to allow for a range of IR opioid that is based around the age of the patient as the single best predictor of opioid dose.⁴³

Patients on opioid agonist therapy

Those patients who are taking preoperative opioids should have any SR or long-acting opioids continued if possible. This also applies to opioids being administered for opioid use disorder. The question of whether to continue buprenorphine/naloxone (Suboxone, Indivior UK Ltd, North Chesterfield, VA, USA) throughout the operative period has previously been debated. However, in a recent systematic review, the majority of patients achieved adequate analgesia when buprenorphine up to 16 mg sublingually daily was continued during the perioperative period.⁴⁴

Patients with opioid use disorder being treated with methadone or buprenorphine/naloxone will be taking much higher opioid doses preoperatively than other patients. It is essential to recognise that in this population, postoperative opioid requirements may be as much as seven to eight times higher once the methadone or buprenorphine/naloxone doses are included⁴⁵ but vulnerability to opioid toxicity is increased. As a consequence, multimodal techniques will need to be utilised to their fullest extent to attain adequate analgesia.

Item 5: long-acting opioids should not be used routinely for acute postoperative pain in opioid-naive patients

It is more than two years since the Australian and New Zealand College of Anaesthetists/Faculty of Pain Medicine (ANZCA/FPM) position statement on the use of SR opioids for acute pain caused consternation throughout our specialties.⁴⁶ The primary message in the statement was that there were excessive risks associated with the use of SR formulations in the opioid-naive surgical patient.

There is also now good evidence demonstrating that the addition of SR opioids does nothing to improve either analgesia or function. This evidence exists for both chronic pain conditions such as osteoarthritis,^47,48 and acute pain, including postoperative pain.⁴⁹ Multiple studies demonstrate that the addition of SR opioids does nothing to improve analgesia but rather can contribute to harm because the overall total opioid dose increases with a predictable attendant increase in adverse events.⁵⁰

It can be challenging to understand how the addition of more opioids could not improve analgesia. The delivery of a background of continuous opioid and the accompanying increase in opioid load has seemed such a commonsense solution to severe postoperative pain that it has been adopted multiple times intravenously and orally over recent decades. Yet each attempt in the adult population has been abandoned as the scrutiny of research makes apparent the lack of benefit and the increased risk.⁵¹

Part of the explanation for this may lie with the fact that the dose–effect curve for mu-agonists is only a straight line at the population level. At an individual level significant variability means that for each patient with opioid-responsive pain, there is a dose that results in a larger incremental reduction in pain. Above that dose, adverse effects increase with little added analgesic benefit. As clinicians, we are tempted to guess what this dose will be when we prescribe SR or regular opioids and to imagine that it will remain stable independent of the time of day, activity levels and the slope of the postoperative pain trajectory.

There is now a long list of regulatory and medical organisations recommending against the use of SR opioids in acute pain. A recent editorial in the British Journal of Anaesthesia stated that as ‘… controlled-release opioid preparations have no benefit and are harmful, there is no longer a routine role for them in contemporary anaesthetic practice’.⁵² There is a good argument that the onus is now on us to justify why we would prescribe them postoperatively to any opioid-naive patient.

Item 6 and 7: a patient-centred approach to discharge prescribing plus safe disposal

There has been significant movement towards reducing excessive prescribing of opioids at discharge. This change in practice is increasingly supported by evidence that more restrictive prescribing at discharge and use of multimodal medications is associated with a shorter duration of opioid use, reduced opioid side-effects, reduced fatigue, and surprisingly but most importantly, less pain.⁵³

Discharge analgesic plans, including non-drug options, should be discussed with the patient and written instructions provided for both the patient and the GP. Opioid usage in the 24–48 hours prior to discharge should be used to guide opioid requirements for discharge. Excellent resources are available for both doctors and patients to help with this process.^54,55

Patients who have been educated about their analgesic plan are able to provide input as to the amount of opioid they would like for discharge. When questioned about their anticipated discharge opioid requirements patients are likely to ask for half the amount of opioid than may otherwise be dispensed and remain just as satisfied with their post-discharge analgesia.⁵⁶ Another advantage of shared decision-making around discharge opioids is that other social factors, for example the availability of assistance at home and access to the GP, will be incorporated into decision-making.

Finally, any discharge analgesic instructions should include a conversation around the principles of safe storage and disposal of any unused medication.⁵⁷

Item 9: other modifiable factors to minimise opioid-induced ventilatory impairment; benzodiazepines

Effective multimodal analgesia optimises the use of non-sedating analgesic techniques. The addition of benzodiazepines in particular substantially increases the risk of sedation/ventilatory impairment. The use and value of diazepam as a ‘muscle relaxant’ is a misnomer. It is a centrally acting depressant with potent synergism for respiratory depression with opioids. It cannot be regarded as either a safe or potent analgesic. If anxiolysis is required there are other ways to provide this more safely. The latest Penington Institute report notes that the combination of opioids with benzodiazepines continues to prove to be the most fatal combination for unintentional drug-induced deaths for Australians.⁵⁸

Hospital strategies

Physicians in the public hospital system are increasingly likely to have electronic ‘forcing functions’ applied to their prescription software that will make it harder to prescribe SR opioids to opioid-naive patients for acute pain. A forcing function is a method to prevent something from happening (the prescription) until certain conditions are met.⁵⁹ Direct intervention at the point of prescribing is a very effective method of changing prescribing behaviour.

While this may be regarded as a draconian method to thwart the right of physicians to prescribe as they see fit, there has been a substantial lead time of physician education around this issue. The release of the ANZCA/FPM statement initiated and facilitated debate, which has been reflected in substantial changes to prescribing behaviour in hospitals,⁵⁰ while GP prescribing appears to be decreasing in metropolitan areas (Liu et al., submitted to Anaesthesia and Intensive Care).

The forcing function solves one of the biggest problems that occurs in public hospitals when education interventions are the sole strategy used to encourage and facilitate change. This is particularly relevant in public hospitals, where there is a constant changeover of staff. It is a very intensive and most likely impossible task to educate every new doctor about every new change in evidence prior to them prescribing. A forcing function acts as a pause, which alerts the doctor that the proposed prescription is not the endorsed practice within the hospital. Links to contact details for the acute pain service may be provided as part of the forcing function, which can allow for consultation if the prescriber believes the case to be an exception. Prescribing is not necessarily prevented but is made more difficult.

Within the private hospital system, however, there is a lower rate of electronic medication charting, there may not be a pain service, and there may be less of an acceptance of the role of forcing functions. We have, however, accepted these functions in other spheres. For example, there is general acceptance of defined limits on prescribing antibiotic prophylaxis. It is important to recognise that forcing functions do not limit prescribing completely because modifications can occur based on the procedure, the patient history and allergies.

An absence of an acute pain service in many private hospitals may make weaning opioids more difficult. There is evidence that at least one visit from an acute pain service decreases the likelihood of unintentional long-term opioid continuation,⁷ demonstrating the benefit of the teachable moment for patients in their contact with hospitals.

When reading these recommendations, we must remain mindful that while education is the necessary bedrock for change, it is on the lowest rung of implementation efficacy. On its own, education is a poor driver of behavioural change. Ongoing structural nudges, such as the upcoming release of the Australian Commission on Quality and Safety in Healthcare Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard⁶⁰ and the use of local procedure-specific analgesic pathways will also be helpful in closing the gap between evidence-based recommendations and practice.

Footnotes

Author Contribution(s)

Jennifer A Stevens: Conceptualization; Methodology; Writing – original draft; Writing – review & editing.

Bernadette R Findlay: Conceptualization; Resources; Writing – original draft; Writing – review & editing.

Declaration of conflicting interests

The author(s) have no conflicts of interest to declare.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Jennifer A Stevens

References

Levy

Quinlan

El-Boghdadly

, et al. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021; 76: 520–536. doi:10.1111/anae.15262

Edwards

Hedrick

Jayaram

, et al. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Perioperative Management of Patients on Preoperative Opioid Therapy. Anesth Analg 2019; 129: 553–566. doi:10.1213/ANE.0000000000004018

Chapman

Donaldson

Davis

, et al. Improving individual measurement of postoperative pain: the pain trajectory. J Pain 2011; 12: 257–262. doi:10.1016/j.jpain.2010.08.005

Althaus

Arránz Becker

Moser

, et al. Postoperative pain trajectories and pain chronification-an empirical typology of pain patients. Pain Med 2018; 19: 2536–2545. doi:10.1093/pm/pny099

Van Boekel

RLM

Bronkhorst

Vloet

, et al. Identification of preoperative predictors for acute postsurgical pain and for pain at three months after surgery: a prospective observational study. Sci Rep 2021; 11: 16459. doi:10.1038/s41598-021-95963-y

Lawal

Gold

Murthy

, et al. Rate and risk factors associated with prolonged opioid use after surgery: a systematic review and meta-analysis. JAMA Netw Open 2020; 3: e207367. doi:10.1001/jamanetworkopen.2020.7367

Jivraj

Scales

Gomes

, et al. Evaluation of opioid discontinuation after non-orthopaedic surgery among chronic opioid users: a population-based cohort study. Br J Anaesth 2020; 124: 281–291. doi:10.1016/j.bja.2019.12.006

Stark

Kerr

Stevens

Prevalence and predictors of persistent post-surgical opioid use: a prospective observational cohort study. Anaesth Intensive Care 2017; 45: 700–706. doi:10.1177/0310057X1704500609

Krebs

Gravely

Nugent

, et al. The SPACE Randomised Clinical Trial. JAMA 2018; 319: 872–882. doi:10.1001/jama.2018.0899

10.

Menendez

Ring

Bateman

BT.

Preoperative opioid misuse is associated with increased morbidity and mortality after elective orthopaedic surgery. Clin Orthop Relat Res 2015; 473: 2402–2412. doi:10.1007/s11999-015-4173-5

11.

Liu

Blake

Naylor

, et al . Letter to the Editor for article titled ‘Opioid tapering/detoxification protocols, a compendium: narrative review’. Pain Med. Epub ahead of print 19 August 2021. doi:10.1093/pm/pnab259

12.

Nguyen

LCL

Sing

Bozic

KJ.

Preoperative reduction of opioid use before total joint arthroplasty. J Arthroplasty 2016; 31: S282–S287. doi:10.1016/j.arth.2016.01.068

13.

Uhrbrand

Rasmussen

Haroutounian

, et al. Shared decision-making approach to taper postoperative opioids in spine surgery patients with preoperative opioid use: a randomized controlled trial. Pain. Epub ahead of print 23 August 2021; doi:10.1097/j.pain.0000000000002456

14.

McPherson

Lederhos Smith

Dobscha

, et al. Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain. Pain 2018; 159: 2097–2104. doi:10.1097/j.pain.0000000000001315

15.

Sullivan

Turner

Di Lodovico

, et al. Prescription opioid taper support for outpatients with chronic pain: a randomized controlled trial. J Pain 2017; 18: 308–318. doi:10.1016/j.jpain.2016.11.003

16.

White

West

Borer

, et al. Risk of cardiovascular events in patients receiving celecoxib: a meta-analysis of randomized clinical trials. Am J Cardiol 2007; 99: 91–98. doi:10.1016/j.amjcard.2006.07.069

17.

Reed

Abdallah

Shao

, et al. Effect of aspirin coadministration on the safety of celecoxib, naproxen, or ibuprofen. J Am Coll Cardiol 2018; 71: 1741–1751. doi:10.1016/j.jacc.2018.02.036

18.

Thybo

Hägi-Pedersen

Dahl

, et al. Effect of combination of paracetamol (acetaminophen) and ibuprofen vs either alone on patient-controlled morphine consumption in the first 24 hours after total hip arthroplasty: the PANSAID Randomized Clinical Trial. JAMA 2019; 321: 562–571. doi:10.1001/jama.2018.22039

19.

Ong

Seymour

Lirk

, et al. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010; 110: 1170–1179. doi:10.1213/ANE.0b013e3181cf9281

20.

Titirungruang

Seresirikachorn

Kasemsuwan

, et al. The use of steroids to reduce complications after tonsillectomy: a systematic review and meta-analysis of randomized controlled studies. Eur Arch Otorhinolaryngol 2019; 276: 585–604. doi:10.1007/s00405-018-5202-2

21.

Nielsen

Siegel

Fomsgaard

, et al. Preoperative dexamethasone reduces acute but not sustained pain after lumbar disk surgery: a randomized, blinded, placebo-controlled trial. Pain 2015; 156: 2538–2544. doi:10.1097/j.pain.0000000000000326

22.

Corcoran

Myles

Forbes

, et al. Dexamethasone and surgical-site infection. N Engl J Med 2021; 384: 1731–1741. doi:10.1056/NEJMoa2028982

23.

Yue

Wei

Liu

Perioperative systemic steroid for rapid recovery in total knee and hip arthroplasty: a systematic review and meta-analysis of randomized trials. J Orthop Surg Res 2017; 12: 100. doi:10.1186/s13018-017-0601-4

24.

Zhou

Jing

, et al. A meta-analysis of dexamethasone for pain management in patients with total knee arthroplasty. Medicine (Baltimore) 2018; 97: e11753. doi:10.1097/MD.0000000000011753

25.

Hida

Murata

Ichinomiya

, et al. Effects of programmed intermittent thoracic paravertebral bolus of levobupivacaine on the spread of sensory block: a randomized, controlled, doubleblind study. Reg Anesth Pain Med 2019; 44: 326–332. doi:10.1136/rapm-2018-100021

26.

Ueda

Manabe

A comparative study of sequential epidural bolus technique and continuous epidural infusion. Anesthesiology 2005; 103: 126–129. doi:10.1097/00000542-200507000-00019

27.

Fettes

Moore

Whiteside

, et al. Intermittent vs continuous administration of epidural ropivacaine with fentanyl for analgesia during labour. Br J Anaesth 2006; 97: 359–364. doi:10.1093/bja/ael157

28.

Jaeger

Baggesgaard

Sørensen

, et al. Adductor canal block with continuous infusion versus intermittent boluses and morphine consumption: a randomized, blinded, controlled clinical trial. Anesth Analg 2018; 126: 2069–2077. doi:10.1213/ANE.0000000000002747

29.

Chong

Wang

Dhir

, et al. Programmed intermittent peripheral nerve local anesthetic bolus compared with continuous infusions for postoperative analgesia: a systematic review and meta-analysis. J Clin Anesth 2017; 42: 69–76. doi:10.1016/j.jclinane.2017.08.018

30.

Doleman

Heinink

Read

, et al. A systematic review and meta-regression analysis of prophylactic gabapentin for postoperative pain. Anaesthesia 2015; 70: 1186–1204. doi:10.1111/anae.13179

31.

Eipe

Penning

Yazdi

, et al. Perioperative use of pregabalin for acute pain – a systematic review and meta-analysis. Pain 2015; 156: 1284–1300. doi:10.1097/j.pain.0000000000000173

32.

Wiffen

Derry

Bell

, et al. Gabapentin for chronic neuropathic pain in adults. Cochrane Database Syst Rev 2017; 6: CD007938. doi:10.1002/14651858.CD007938.pub4

33.

Weibel

Jelting

Pace

, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev 2018; 6: CD009642. doi:10.1002/14651858.CD009642.pub3

34.

Challapalli

Tremont-Lukats

McNicol EDet al. Systemic administration of local anesthetic agents to relieve neuropathic pain. Cochrane Database Syst Rev 2005; 4: CD003345. doi:10.1002/14651858.CD003345.pub2

35.

Jessen

Korvenius

Møller

AM.

Perioperative dexmedetomidine for acute pain after abdominal surgery in adults. Cochrane Database Syst Rev 2016; 2: CD010358. doi:10.1002/14651858.CD010358.pub2

36.

Song

Shim

Song

, et al. Dexmedetomidine added to an opioid-based analgesic regimen for the prevention of postoperative nausea and vomiting in highly susceptible patients. Eur J Anaesthesiol 2016; 33: 75–83. doi:10.1097/EJA.0000000000000327

37.

Nielsen

Fomsgaard

Siegel

, et al. Intraoperative ketamine reduces immediate postoperative opioid consumption after spinal fusion surgery in chronic pain patients with opioid dependency: a randomised, blinded trial. Pain 2017; 158: 463–470. doi:10.1097/j.pain.0000000000000782

38.

Pendi

Field

Farhan

, et al. Perioperative ketamine for analgesia in spine surgery: a meta-analysis of randomized controlled trials. Spine 2018; 43: E299–E307. doi:10.1097/BRS.0000000000002318

39.

Xiao

Feng

, et al. Efficacy and safety of tapentadol immediate release assessment in treatment of moderate to severe pain: a systematic review and meta-analysis. Pain Med 2017; 18: 14–24. doi:10.1093/pm/pnw154

40.

Daniels

Casson

Stegmann

, et al. A randomised, double-blind, placebo-controlled phase 3 study of the relative efficacy and tolerability of tapentadol IR and oxycodone IR for acute pain. Curr Med Res Opin 2009; 25: 1551–1561. doi:10.1185/0300799090295282

41.

Nielsen

Crossin

Middleton

, et al. Comparing rates and characteristics of ambulance attendances related to extramedical use of pharmaceutical opioids in Australia: a protocol for a retrospective observational study. BMJ Open 2019; 9: e029170. doi:10.1136/bmjopen-2019-029170

42.

Schug

SA.

The atypical opioids buprenorphine, tramadol and tapentadol. Med Today 2019; 20: 31–36.

43.

Macintyre

Jarvis

DA.

Age is the best predictor of postoperative morphine requirements. Pain 1996; 64: 357–364. doi:10.1016/0304-3959(95)00128-X

44.

Goel

Azargive

Lamba

, et al. The peri-operative patient on buprenorphine: a systematic review of peri-operative management strategies and patient outcomes. Can J Anesth 2019; 66: 201–217. doi:10.1007/s12630-018-1255-3

45.

Hansen

Stone

Matson

, et al. Total joint arthroplasty in patients taking methadone or buprenorphine/naloxone preoperatively for prior heroin addiction: a prospective matched cohort study. J Arthroplasty 2016; 31: 1698–1701. doi:10.1016/j.arth.2016.01.032

46.

Australian and New Zealand College of Anaesthetists. Position statement on the use of slow-release opioid preparations in the treatment of acute pain. http://www.anzca.edu.au/resources/endorsed-guidelines/positionstatement-on-the-use-of-slow-release-opioids (2018, accessed 14 September 2021).

47.

Pedersen

Borchgrevink

Riphagen

, et al. Long- or short-acting opioids for chronic non-malignant pain? A qualitative systematic review. Acta Anaesthesiol Scand 2014; 58: 390–401. doi:10.1111/aas.12279

48.

Ghodke

Barquero

Chelminski

, et al. Short-acting opioids are associated with comparable analgesia to long-acting opioids in patients with chronic osteoarthritis with a reduced opioid equivalence dosing. Pain Med 2018; 19: 2191–2195. doi:10.1093/pm/pnx245

49.

Tan

Bugeja

Begley

, et al. Postoperative use of slow-release opioids: the impact of the Australian and New Zealand College of Anaesthetists/Faculty of Pain Medicine position statement on clinical practice. Anaesth Intensive Care 2020; 48: 444–453. doi:10.1177/0310057X20956664

50.

Awadalla

Liu

Kemp-Casey

, et al. Impact of an Australian/New Zealand organisational position statement on extended-release opioid prescribing among surgical inpatients: a dual centre before-and-after study. Anaesthesia 2021; 76: 1607–1615. doi:10.1111/anae.15500

51.

George

Lin

Hanna

, et al. The effect of intravenous opioid patient-controlled analgesia with and without background infusion on respiratory depression: a meta-analysis. Opioid Manag 2010; 6: 47–54. doi:10.5055/jom.2010.0004

52.

Levy

Mills

Controlled-release opioids cause harm and should be avoided in management of postoperative pain in opioid naıve patients. Br J Anaesth 2019; 122: e86–e90. doi:10.1016/j.bja.2018.09.005

53.

Fleischman

Tarabichi

Foltz

, et al. Cluster-randomized trial of opiate-sparing analgesia after discharge from elective hip surgery. J Am Coll Surg 2019; 229: 335–345. doi:10.1016/j.jamcollsurg.2019.05.026

54.

Faculty of Pain Medicine (FPM), Australian and New Zealand College of Anaesthetists. Better pain management: pain education for health professionals. https://www.betterpainmanagement.com/ (accessed 13 November 2021).

55.

National Prescribing Service. Managing pain and opioid medicines, NPS MedicineWise. https://www.choosingwisely.org.au/assets/CW-Patient-resource-Opioids_1.pdf (accessed 13 November 2021).

56.

Vilkins

Sahara

Till

, et al. Effects of shared decision making on opioid prescribing after hysterectomy. Obstet Gynecol 2019; 134: 823–833. doi:10.1097/AOG.0000000000003468

57.

The National Return and Disposal of Unwanted Medicines Limited. The National Return and Disposal of Unwanted Medicines Program. http://www.returnmed.com.au/ (accessed 13 November, 2021).

58.

Penington Institute. Australia’s Annual Overdose Report 2021. Melbourne: Penington Institute, August 2021. ISSN: 2652–7790.

59.

Grissinger

Building patient-safety skills: avoiding pitfalls in conducting a root cause analysis. P&T: a peer-reviewed journal for formulary management 2013; 38: 728–729. PMID: 24391394; PMCID: PMC3875263.

60.

Australian Commission on Quality and Safety in Healthcare. Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard. https://www.safetyandquality.gov.au/standards/clinical-care-standards/opioid-analgesic-stewardship-acute-pain-clinical-care-standard (accessed 13 November 2021).

How to close the gaps between evidence and practice for perioperative opioids

Abstract

Keywords

Introduction

Recommendations for best clinical practice

How do we implement the most modifiable points in the recent statement?

Items 1 and 2: preoperative communication and planning

Item 4: optimise multimodal analgesia. What does this mean now?

Maximise simple analgesic use

Dexamethasone extended applications

Regional blocks and local anaesthetic catheter techniques as background analgesia

Gabapentinoids

Infusions

Choice of opioid type and dose

Patients on opioid agonist therapy

Item 5: long-acting opioids should not be used routinely for acute postoperative pain in opioid-naive patients

Item 6 and 7: a patient-centred approach to discharge prescribing plus safe disposal

Item 9: other modifiable factors to minimise opioid-induced ventilatory impairment; benzodiazepines

Hospital strategies

Footnotes

Author Contribution(s)

Declaration of conflicting interests

Funding

ORCID iD

References