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Abstract

Background

Chronic post-surgical pain (CPSP) and persistent post-operative opioid use (PPOU) are inconsistently defined in published literature. This review comprehensively summarised their definitions, prevalence and determinants from existing systematic reviews or meta-analyses.

Methods

Systematic reviews or meta-analyses evaluating the prevalence of CPSP and PPOU in adults after surgeries were retrieved from an electronic database search applying structured search strategies in PubMed, MEDLINE, Embase, CINAHL Plus and Cochrane Database of Systematic Reviews from inception to 31 December 2022. Two reviewers selected systematic reviews, extracted data regarding the definition, prevalence and risk factors of CPSP and PPOU and assessed the quality using the AMSTAR 2 tool.

Results

The study identified 6936 records related to chronic pain and persistent opioid use in patients after surgery, of which 24 articles were identified for full-text review. Eighteen systematic reviews were included in this umbrella review, of which five systematic reviews assessed chronic pain in patients who had undergone a surgical procedure, and 13 reviews assessed persistent opioid use after surgery. Despite considerable variations in patient characteristics (from age ≥18 years), types of surgeries, follow-up duration and the definitions of measures, most reviews were of medium to good quality (fulfilled 9-11/16 AMSTAR 2 criteria). The prevalence of CPSP and PPOU, commonly synthesised at 3, 6 or 12 months after surgeries, varied from 5%–58% and 2%–65%, respectively, despite various terminologies, definitions and timing of measures and associated determinants. The prevalence of neuropathic pain in CPSP was obtainable for four surgeries, with 9%–74%.

Conclusion

To inform future practice and policy to optimise pain management and opioid safety, consensus on standardising measurements and further studies assessing risk factors associated with CPSP, PPOU and adverse outcomes are needed.

Keywords

persistent post-operative opioid use surgery chronic pain post-operative pain opioid dependence prevalence

Introduction

Surgical procedures are crucial in treating and managing various medical conditions, with more than 350 million surgeries performed globally annually.¹ Severe and acute pain is commonly related to temporary tissue damage or permanent anatomical impairment after invasive procedures, especially following major surgery, which can result in chronic pain if not managed appropriately.² Chronic post-surgical pain (CPSP) refers to pain that does not present before surgery, localises at the incision site or related areas of the surgery, and persists for at least three months post-surgery.^3–5 However, the prevalence of CPSP is still inconclusive due to the diverse patient populations, complexity of surgical procedures and non-standardised measures of CPSP.⁶ Although nerve injury during surgery has been implicated in developing CPSP, not all patients with nerve damage develop CPSP.⁷

Furthermore, unresolved persistent pain could detriment individuals’ quality of life and result in a medical and financial burden to patients and the healthcare system, as patients with chronic pain commonly suffer from physical, functional and emotional disabilities (e.g. depression and anxiety).^6,8,9 Emerging evidence from North American countries indicates an increase in persistent post-operative opioid use (PPOU) after surgery,^10–16 despite various prevalence and definitions reported. Opioids are potent analgesics with a dependent tendency commonly used for post-surgical pain.^17,18 Excessive opioid prescribing after surgery has been recognised as a contributor to the crisis of opioid addiction and overdose in the United States.¹⁹

Similar to CPSP, the epidemiology of PPOU is poorly characterised despite its potential public health importance. PPOU is widely defined as the long-term use of opioids, for example, filling multiple opioid prescriptions within 90 to 180 days after discharge from surgery,²⁰ although various definitions exist.^21–24 The prevalence of PPOU varies due to the considerable variation in defining persistent use across studies, and the determinants of PPOU and its consequences are still inconclusive.²¹ Currently, there is no robust evidence supporting the effectiveness of long-term opioid use. Still, persistent and high-dose opioid use is closely related to opioid-related harm, such as dependence, misuse and adverse conditions (e.g. hypoxia, cardiovascular events and depression) contributing to unwanted incidents (e.g. opioid-related deaths).^25–27 A better understanding of the prevalence, determinants and consequences of PPOU is vital to inform the decision of post-surgical pain management strategies and optimise opioid use.

A complex causal relationship exists between surgery, chronic pain, persistent opioid use and opioid-related detrimental outcomes. Various factors, such as patients’ characteristics and types of surgery, may affect the risk of chronic pain, opioid-related problems (e.g. persistent or high-dose use), opioid-related harm and other detrimental outcomes (e.g. cardiovascular diseases, fractures or opioid-related deaths).²⁸ Several previously published systematic reviews have found a wide variation in the prevalence of CPSP and PPOU due to various measures, sample sizes of the study population and types of surgical procedures.²⁹ An overview of systematic reviews (i.e. an umbrella review) can summarise and compare evidence synthesised in previous research to support evidence-informed clinical or research decision-making.^30–32 Therefore, this umbrella review aimed to investigate the prevalence of CPSP and PPOU as evidenced by systematic reviews to inform future clinical or research agendas for optimising post-surgical pain management and opioid use.

Methods

This systematic review followed the Preferred Reporting Items for Overviews of Reviews (PRIOR) guideline.³³ The protocol was registered with PROSPERO prospectively (CRD42022334418) to address the prevalence of chronic pain and persistent opioid use after major surgeries synthesised in systematic reviews or meta-analyses.

Eligibility of criteria

This review included published systematic reviews or meta-analyses synthesising the risk of chronic pain and persistent opioid use in the adult population (or those aged ≥18 years) who underwent the selected major elective surgical procedures. Following the PICO framework, population, outcome, type of studies, type of publication and language were defined³⁴ (Appendix 1). There were two types of outcomes and no restrictions on the follow-up period. Systematic reviews that only focused on non-elective and day surgical procedures or only evaluated parenteral opioids (intravenous, intramuscular and subcutaneous) were excluded. Studies were limited by those published in the English language only. Other publication types, such as narrative reviews, observational studies and randomised controlled trials, were excluded (Appendix 1).

Search strategy and information source

Electronic database searches were conducted using structured search strategies on Ovid MEDLINE, Embase, CINAHL and Cochrane Database of Systematic Reviews from inception to 31st December 2022 to identify systematic reviews or meta-analyses assessing chronic pain and persistent opioid use and opioid-related outcomes in the population receiving surgeries. Controlled vocabulary (e.g. Medical Subject Headings) and relevant terms of major surgeries were searched and combined with terms for identifying chronic pain (Appendix 2) and persistent opioid use (Appendix 3). The reference lists of the included systematic reviews were also scanned for other relevant articles.

Selection process

All search results were imported into a reference management programme (EndNote 20). After removing duplicates, one reviewer screened titles and abstracts by applying the inclusion or exclusion criteria (Appendix 1) and identified articles eligible for further review. Two investigators reviewed the full text of the short-listed articles and discussed any discrepancies. The reasons for exclusion were also documented and summarised.

Data extraction

From each included systematic review, authors’ information (author's name, publication year and country), methodology (study design, setting, study cohort, method, data source, outcomes, definition of outcome measures, determinants and methods of analysis) and results were retrieved by two independent reviewers (NB and SA). The outcome data retrieved included the definition (measurement and timing) of CPSP and PPOU, the prevalence and associated factors.

Risk of bias

The quality of systematic reviews was assessed by two independent reviewers (NB and SA) using the AMSTAR 2 (A Measurement Tool to Assess Systematic Reviews) tool, a 16-item checklist commonly used to appraise systematic reviews that include randomised or non-randomised studies of healthcare interventions or both.³⁵ Systematic reviews were classified as medium to good quality if they fulfilled 9 to 11 over 16 items of the AMSTAR 2 tool.³⁵

Data synthesis

The primary outcome of this review was the prevalence of chronic pain and persistent opioid use after major surgery. The pooled prevalence rate, with a 95% confidence interval (95% CI), and the heterogeneity measure (I²) identified from each meta-analysis, as well as the mean with range or median with interquartile range (IQR) identified from each systematic review, were presented. Risk factors associated with the occurrence of primary outcomes were also summarised. The odds ratio (OR) or relative risk (RR) with 95% CI and I² were extracted from each systematic review that indicated an increasing risk (i.e. OR or RR greater than one) were extracted and presented. All these results were synthesised narratively, presented graphically as tables and compared between various types of surgeries and follow-up duration. The following result section reported the characteristics of included systematic reviews (or meta-analysis), the prevalence and factors associated with CPSP and PPOU, respectively. Besides, the severity of CPSP reported in those systematic reviews was also summarised.

Results

Selection of studies

The database search identified 6936 records of chronic pain and persistent opioid use in patients after surgery. After removing duplicates, titles and abstracts, 6758 remaining records were screened. A further 6734 studies were excluded due to unfit study types (i.e. observational studies, protocols, randomised controlled trials and reviews) or matching at least one of the exclusion criteria. Of the eligible 24 articles identified for full-text review, additional six articles were excluded for not meeting the inclusion criteria (Figure 1). This umbrella review included 18 systematic reviews published between 2009 and 2022.^{24,34,36–51} Of these, five were systematic reviews (with three meta-analyses) assessing chronic pain in patients who had undergone a surgical procedure,^34,36–39 and 13 were systematic reviews (with nine meta-analyses) assessing persistent opioid use after surgery.^24,40–51

Risk of bias assessments

Most of the included systematic reviews were of moderate to high quality according to the 16-item AMSTAR 2 assessment tool.³⁵ All 18 systematic reviews included the PICO (population, intervention, comparison and outcome) component⁵² and reported reasons for excluding studies. Other items were either partially met or unmet. Most systematic reviews neither justify the selection of study designs nor provide a list of excluded studies (Appendix 4).

Systematic reviews on the prevalence of chronic post-surgical pain

Characteristics of included systematic reviews of chronic post-surgical pain

The five systematic reviews (with three meta-analyses) assessing chronic pain in patients who had undergone a surgical procedure^{34,36–38,42} were conducted by researchers from different countries (Germany, Denmark, United States, New Zealand and Portugal) and published in 2009 to 2017 (Table 1). These systematic reviews included various types of studies, including prospective cohort studies,^36–38,42 retrospective cohort studies,^34,37,38 case-control studies,³⁸ cross-sectional studies^37,42 and randomised controlled trials³⁷ with adults receiving various major surgeries. Except for Lewis et al.'s (2015) review,⁴² four systematic reviews reported the prevalence of chronic pain after surgery.

Various terminology has been applied in the systematic reviews to include studies of chronic pain after surgery (Table 1), including persistent post-surgical pain, long-term pain, CPSP and chronic pain. Except for Haroutiunian et al.’s (2013) study using an unspecified term (i.e. persistent post-surgical pain),³⁴ CPSP was defined as pain lasting ≥3 months after surgery in the other four systematic reviews. These definitions did not include pain frequency, intensity and temporal and anatomical relationship to surgery.³⁴ Besides, various follow-up timeframes (from 3 months to 9 years) were also employed to measure chronic pain. Two systematic reviews indicated neuropathic pain as a possible component of CPSP. They evaluated its prevalence after cardiac surgery³⁷ and various major surgeries³⁴ (Table 1).

Prevalence of chronic post-surgical pain

The prevalence of patients with CPSP was reported in three systematic reviews^34,36,37 (Table 2). Haroutiunian et al. (2013) reported median and IQR of the CPSP prevalence and indicated that the lowest proportion of CPSP was in patients with varicose vein surgery (4.7%; IQR: 4.0%, 13.0%) followed by groin hernia repair (7%; IQR: 2.5%,19.0%); and the proportion was higher after thoracic surgery (34.5%; IQR: 21.0%, 52.0%), breast surgery (31.0%; IQR: 21.5%, 47.3%) and total hip or knee arthroplasty (19.8%; IQR: 11.7%, 27.7%), depending on various interventions or follow-up time for measuring the pain.³⁴ Furthermore, the two meta-analyses synthesised the pooled results of CPSP prevalence, ranging from 43% to 58% after thoracotomy³⁶ and 16.6% to 37.1% after cardiac surgery³⁷ (Table 2).

Notably, for the prevalence of neuropathic pain after surgery, Haroutiunian et al. (2013) found that a reliable estimate of neuropathic pain in CPSP was only obtainable for four (out of 11) types of surgeries. The proportion of patients with ‘definite or probable neuropathic pain’ was lowest after total hip or knee arthroplasty (9% vs 6%), followed by hernia surgery (45% vs 31%), thoracotomy (52% vs 66%) and mastectomy (74% vs 68%).³⁴ The authors suggested studies that employed stringent criteria for chronic pain (e.g. patients with pain intensity for more than three out of 10 on a visual analogue scale) reported a lower prevalence of CPSP as compared with those with loose criteria (e.g. any pain), which may have overestimated the prevalence.³⁴

The severity of chronic post-surgical pain

The two systematic reviews and meta-analyses of CPSP after thoracotomy and cardiac surgery also reported the intensity of pain.^36,37 Bayman et al. (2014) synthesised the mean score of 0-100 numeric rating scale at 3, 6 and 12 months (30 ± 2, 32 ± 7 and 26 ± 9) after thoracotomy or video-assisted thoracoscopy from three studies that were significantly greater than 0,³⁶ which mean patients had at least moderate pain.

On the other hand, Guimaraes-Pereira et al. (2017) synthesised the proportion of patients who reported moderate CPSP at three periods after cardiac surgery: three to less than 6 months (39.6%; 95% CI: 33.5%, 45.8%), 12 to less than 24 months (43.4%; 95% CI: 30.9%, 55.9%) and at least 24 months after surgery (50.1%; 95% CI: 37.5%, 62.8%) with tremendous heterogeneity (I² ranged from 53% to 89%). Likewise, a high proportion of patients reported worst pain at 12 to less than 24 months (48.8%, 95% CI: 41.8%, 55.9%; I²: 13.36%) and at least 24 months (61.5%; 95% CI: 53.6%, 69.5%; I²<0.1%) after surgery.³⁷

Factors predicting chronic post-surgical pain

Two systematic reviews reported factors associated with CPSP.^38,42 Hinrichs-Rocker et al. (2009) scored risk factors associated with CPSP from one to 3 (1: likely association; 2: inconclusive association and 3: unlikely association) and reported that depression, psychological vulnerability, stress and the duration of disability (late return to work) were most likely associated with CPSP.³⁸

On the other hand, Lewis et al. (2015) conducted a univariate meta-regression analysis and found that demographics (age, gender and weight), mental health diseases (anxiety and depression), pain-related factors (e.g. pre-operative pain, pain catastrophising and pain sites), social support and pre-operative function were predictors of CPSP. However, in the multivariable models, only pre-operative pain (0.159; 95% CI: 0.077, 0.240), pain catastrophising (0.302; 95% CI: 0.162, 0.441), co-morbidities (0.047; 95% CI: 0.016, 0.790) and mental health disease (-0.108; 95% CI: -0.148, -0.068) had a significant association with the prevalence of CPSP (the effect sizes and 95% CIs were derived from the Fisher's Z analysis).⁴²

Systematic reviews on the prevalence of persistent post-operative opioid use

Characteristics of included systematic reviews of persistent post-operative opioid use after surgery

Thirteen systematic reviews, including nine meta-analyses, assessed persistent opioid use after surgery and were published by researchers from the United States (n = 6),^{24,40,41,46,48,50} Canada (n = 3),^39,43,51 Australia (n = 2)^47,49 United Kingdom (n = 1)⁴⁴ and China (n = 1),⁴⁵ after 2018 (Table 3). These systematic reviews mainly included observational studies (although five reviews^39,44–47 did not specify the type of studies) on patients who underwent various surgical procedures from surgical or traumatic settings.

There was considerable variation in the definitions of PPOU (Table 3). The terms – prolonged, chronic or persistent post-operative opioid use – were used interchangeably. Generally, any opioid use pattern (commonly defined by a prescription filled) reported by the included studies occurring at least 3 months (or 90 days) after surgery was considered PPOU. Mohamadi et al. (2018) retrieved any definitions of PPOU from each included study. They found studies predominantly defined PPOU as opioid use beyond 2 months following surgery or trauma, and opioids within 30 days after surgery was often regarded as short-term use.²⁴ The other 12 systematic reviews included studies that measured PPOU at >3 (or ≥3) months, 3–6 months or >6 months.^{39–41,43–51} However, there was no consistency in measuring the exposure to opioids during these periods (Table 3).

Despite the inconsistent definition of PPOU, some systematic reviews applied various definitions in sensitivity analyses to explore how various PPOU measures influenced PPOU prevalence. For example, in addition to prolonged opioid use, Lawal et al. (2020) defined persistent opioid use as receiving (a) ≥10 opioid prescription fills, at least 90 consecutive days’ supply of opioids or (b) 120 cumulative days in the first year after surgery, excluding the initial 90 post-operative days.⁴¹ Other systematic reviews also employed a broader definition (e.g. filling at least one opioid prescription) or a shorter cut-off period (e.g. ‘after 60 days’ as opposed to ‘after 90 days’) of measuring opioid use and reported a higher prevalence rate of PPOU.^44,45

Furthermore, various definitions were applied to measure pre-operative opioid use and dichotomised into opioid naïve and opioid use. In the systematic review by Hinther et al. (2019), inconsistent definitions of pre-operative opioid use, including any opioid use within 3 months, opioid use for greater than 3 months before surgery or unspecified definition, were identified.³⁹ Page et al. (2020) dichotomised pre-operative opioid use into no/short-term and prolonged use according to whether any opioid prescription was within 1 month before surgery.⁴³

Prevalence of persistent post-operative opioid use

Overall, 12 systematic reviews that reported the prevalence of PPOU, including eight systematic reviews and meta-analyses, synthesised the pooled rates with 95% CI,^{24,41,45,47–51} and three systematic reviews summarised the mean³⁹ or median^43,44 and one systematic review summarised the ranges⁴⁰ (Table 4). The prevalence of PPOU was commonly presented by stratifying various types of surgeries, patients’ prior opioid exposure or other characteristics of included studies (e.g. countries, length of follow-up and study settings) in these systematic reviews.

Regardless of the history of pre-operative opioid use, the prevalence of PPOU ranged from 2% to 65%. The pooled PPOU prevalence rate in total joint arthroplasty (12%; 95% CI: 10.0%, 14.0%) reported by Wu et al. (2021)⁴⁵ is similar to the rate in orthopaedic surgery (12.1%; 95% CI: 9.7%, 14.9%) by Lawal et al. (2020).⁴¹ However, these results profoundly differ from the systematic review by Hinther et al. (2019), which showed that the mean PPOU prevalence ranged from 8% to 55% during 3 to 12 months after any surgery (Table 4).

The PPOU prevalence is notably higher in pre-operative opioid users than in opioid-naïve patients. In the meta-analysis by Lawal et al. (2020), the pooled rate was 13.8% (95% CI: 7.9%, 23.0%) and 2% (95% CI: 0.4%, 3.9%) for pre-operative prolonged opioid users versus opioid-naïve patients, respectively.⁴¹ Page et al. (2020) and Hinther et al. (2019) also found the same pattern with an apparent gap in PPOU rates between pre-operative opioid users and opioid-naïve patients, regardless of the definition of pre-operative opioid use (Table 4).

Factors predicting persistent post-operative opioid use

Six meta-analyses^{24,41,45,46,48,50} and one systematic review⁴³ reported risk factors associated with the prevalence of PPOU (Table 5). The narrative summary of Page et al. (2020) is listed separately in Appendix 5.⁴³

It is worth noting that these factors’ effect size and significance highly depend on the analytical models and covariates included in the models. For example, the type of surgery or prior opioid use was often used to stratify patients’ subgroups. Furthermore, the reference category of these categorical variables, for example, comparing females against males, lower against higher education rank, and other ethnicity categories against white ethnicity, may also influence the effect size.⁴¹

Despite vast heterogeneity and regardless of the number of studies, PPOU was also associated with female sex and type of surgery. For the existing pain conditions, the highest OR was found in patients with back pain (pooled OR range: 1.45 to 2.1), followed by chronic pain (1.35 to 1.37), fibromyalgia, and migraine. Of all the mental health disorders, psychiatric disorders (pooled OR 1.9 to 2.7) and depression (pooled OR range: 1.54 to 1.62) had the largest effect size. In addition to cocaine, alcohol, tobacco and substance (unspecified) abuse were also found to be associated with PPOU. Furthermore, pre-operative medication use (i.e. antidepressants, benzodiazepines and non-steroidal anti-inflammatory drugs) and other co-morbidities (e.g. pulmonary, cardiovascular, blood and liver diseases and diabetes) were also associated with PPOU (Table 5).

Discussion

This umbrella review provides a comprehensive summary of the available evidence on the prevalence of CPSP and PPOU. Our findings indicate that CPSP is a common complication after surgery, with prevalence estimates ranging from 4.7% to 58% depending on the type of surgery and follow-up time. Moreover, PPOU is also a significant concern, with prevalence estimates ranging from 2% to 65%. CPSP and PPOU are complex conditions arising from biological, psychological and social factors.²⁹ Surgical trauma and nerve injury can lead to ongoing pain, while changes in the central nervous system can amplify pain perception.⁵³ Inflammatory responses and neuropathic pain play significant roles, and individual variability influences how pain and opioids affect different individuals.⁵⁴ Prolonged opioid use may lead to opioid-induced hyperalgesia, tolerance and dependence. Social and environmental factors can further influence outcomes.⁵⁵

From the included systematic reviews, CPSP is often measured 3–12 months after surgery, and patients who had CPSP were at least with moderate pain once they had experienced pain. However, the current definitions of CPSP do not include pain frequency, intensity and temporal and anatomical relationship to surgery. Furthermore, the mechanism (pathophysiology) of developing chronic pain after surgery is not fully understood. Previous reviews by Macrae et al. (2008) and VanDenKerkhof et al. (2013) proposed that the mechanism underlying CPSP is partly neuropathic due to the possibility of nerve damage during invasive surgery.^3,56 Nevertheless, the lack of uniformity and reporting in assessing neuropathic pain introduces the risk of misclassification and restricts the understanding of the characteristics of CPSP and the potential mechanisms of CPSP development.

The current evidence underpinning the predictors of CPSP is also limited. Despite so, of the two studies that predicted the factors associated with the prevalence of CPSP, Hinrichs-Rocker et al.³⁸ reported depression, psychological vulnerability, stress and the duration of disability (late return to work) as the risk factors associated with CPSP. Similarly, Lewis et al. (2015) also found a significant association between CPSP and mental health illnesses, pre-operative pain, pain catastrophising and any existing co-morbidities.⁴² Pain catastrophising is a negative cognitive-affective response to anticipated or actual pain.⁵⁷ Knowledge of the risk factors of CPSP would allow healthcare professionals to identify patients at increased risk in clinical practice. Therefore, future research needs to further differentiate the study population, type of surgery and type of pain during the follow-up period for further defining and measuring CPSP.

Consistently, this umbrella review revelated the complicated and inconsistent definitions of PPOU in previously published systematic reviews. The included literature defined PPOU as whether an opioid prescription is refilled within certain days. Although persistent opioid use can be defined by ‘number of prescriptions’, ‘prescription gap’ and ‘number of days’, there is no consensus on measuring persistent opioid use. Moreover, PPOU has also been used interchangeably with terms such as ‘prolonged’ or ‘chronic’ pain. These inconsistencies in the definitions of PPOU make it challenging to evaluate the prevalence of PPOU and its detrimental consequences.

In the systematic review by Jivraj et al. (2020), 29 unique definitions of PPOU were found from included cohort studies that measured a patient's opioid use at least 30 days after discharge from surgery (literature searched from 1946 to June 2018).²⁰ The authors applied those definitions in a cohort of 162,830 opioid-naive surgical patients and identified the median incidence of persistent opioid use in 1 year after surgery was 0.7% (range: 0.01% to 14.7%).²⁰ Due to the considerable variation in incidence, although the authors attempted to associate PPOU and opioid-related overdose or diagnosis associated with opioid use disorder, the sensitivity of each definition was low.²⁰

Similar to the factors influencing CPSP, the heterogeneity in the prevalence of PPOU is also multifactorial. The factors associated with a significant and higher risk of PPOU were retrieved from the three meta-analyses^24,41,45 and categorised into seven groups, including demography, type of surgery, existing pain conditions, mental health disorders, substance misuse/abuse, prior medication use and other co-morbidities. Notably, the most significant pooled odd ratios were for patients with cocaine abuse and pre-operative opioid use. Previous studies also implied that patients who use opioids before surgery might develop increased tolerance and opioid-induced hyperalgesia due to reduced sensitivity.^58,59 Consequently, these patients require higher doses of opioids to control their pain, which may increase the risk of PPOU and opioid-related harms, for example, drug-related mortality.⁶⁰ However, various measures of pre-operative opioid use may also influence casual inferencing between pre-operative opioid use and PPOU^61,62; hence, a consensus on defining pre-operative opioid use is required and adopted in future studies.

This study presents a comprehensive overview of existing systematic reviews related to surgery and chronic pain and surgery and persistent opioid use, particularly an overview of where the current evidence lies and the current gaps in knowledge. Knowing the risk factors associated with both outcomes allows predicting patients at increased risk of long-term opioid use.

One of the study's limitations is the lack of predefined quality standards for including systematic reviews in the review. Consequently, review quality assessment relies on the standards applied in the original review, which vary in rigour and consistency. Observational studies inferring PPOU and opioid-related detrimental outcomes might be biased by confounding factors, such as poor quality of life, co-morbidities (e.g. pre-existing hypertension) or concurrent medicines (e.g. anti-hypertensives-related dizziness, falls and fractures)⁶³ For example, poor quality of life may cause distress, financial struggles (e.g. due to job losses), and subsequently, confront illicit drug use (e.g. opioids), leading to opioid-related overdose and deaths.⁶⁴ Therefore, appropriate study designs and cautious interpretations are needed to assess the relationship between surgery and these outcomes.

Conclusion

The prevalence of CPSP and PPOU reported in the published systematic reviews varied greatly due to the inconsistent definitions, measuring time and different cohort characteristics. Inconsistency in the prevalence of CPSP and PPOU detriments the accuracy of identifying predictors of each outcome. Future studies need to reach a consensus with the definitions of CPSP and PPOU, the reporting and evaluation of risk factors and the justifications for the effectiveness of interventions.

Supplemental Material

Supplemental Material - Prevalence and determinants of chronic pain and persistent opioid use after surgery: A review of systematic reviews

Supplemental Material for Prevalence and determinants of chronic pain and persistent opioid use after surgery: A review of systematic reviews by Neetu Bansal, Sheanne Ang, and Li-Chia Chen in British Journal of Pain

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study has been undertaken as part of a UK NIHR-funded Clinical Doctoral Research Fellowship (Award number NIHR301585).

ORCID iD

Neetu Bansal

Supplemental Material

Supplemental material for this article is available online.

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