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December 8, 2021

Current Issues in the Use of Opioids for the Management of Postoperative Pain: A Review

Author Affiliations
  • 1Department of Anaesthesia, Pain Medicine and Hyperbaric Medicine, Royal Adelaide Hospital and Discipline of Acute Care Medicine, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
  • 2Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
  • 3Department of Anaesthesia and Perioperative Medicine, West Suffolk NHS Foundation Trust, Bury St Edmunds, Suffolk, United Kingdom
  • 4Gastrointestinal Surgery, Nottingham Digestive Diseases Centre, National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, United Kingdom
  • 5MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, United Kingdom
JAMA Surg. 2022;157(2):158-166. doi:10.1001/jamasurg.2021.6210

Importance  Uncontrolled and indiscriminate prescribing of opioids has led to an opioid crisis that started in North America and spread throughout high-income countries. The aim of this narrative review was to explore some of the current issues surrounding the use of opioids in the perioperative period, focusing on drivers that led to escalation of use, patient harms, the move away from using self-reported pain scores alone to assess adequacy of analgesia, concerns about the routine use of controlled-release opioids for the management of acute pain, opioid-free anesthesia and analgesia, and prescription of opioids on discharge from hospital.

Observations  The origins of the opioid crisis are multifactorial and may include good intentions to keep patients pain free in the postoperative period. Assessment of patient function may be better than unidimensional numerical pain scores to help guide postoperative analgesia. Immediate-release opioids can be titrated more easily to match analgesic requirements. There is currently no good evidence to show that opioid-free anesthesia and analgesia affects opioid prescribing practices or the risk of persistent postoperative opioid use. Attention should be paid to discharge opioid prescribing as repeat and refill prescriptions are risk-factors for persistent postoperative opioid use. Opioid stewardship is paramount, and many governments are passing legislation, while statutory bodies and professional societies are providing advice and guidance to help mitigate the harm caused by opioids.

Conclusions and Relevance  Opioids remain a crucial part of many patients’ journey from surgery to full recovery. The last few decades have shown that unfettered opioid use puts patients and societies at risk, so caution is needed to mitigate those dangers. Opioid stewardship provides a multilayered structure to allow continued safe use of opioids as part of broad pain management strategies for those patients who benefit from them most.

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