Discharge postoperative opioids increase adverse events without improving pain management

1. There was no significant difference in pain reduction between patients in the opioid and non-opioid analgesia group.

2. The most prescribed opioids, in order, were codeine, hydrocodone and tramadol.

Level of evidence assessment: 1 (Excellent)

Summary of the study: Opioids are commonly prescribed for the management of postoperative pain following major surgical procedures. However, in recent decades their use has become so widespread that even minor procedures present the possibility for opioid-naïve patients to become opioid-dependent. There is little evidence regarding the effectiveness of opioid analgesia compared to nonopioid analgesia for postoperative pain for less severe procedures. This systematic review and meta-analysis aimed to compare the clinical effectiveness of opioids and non-opioid analgesia for the management of postoperative pain. The primary outcome was self-reported pain on day 1 post discharge and vomiting up to 30 days post discharge. According to the study results, postoperative analgesia with opioids did not significantly reduce pain compared to analgesia without opioids. In contrast, the authors found an increased frequency of vomiting in the opioid analgesic group compared to non-opioids. This study was well designed and included randomized controlled trials over more than three decades, which added to the validity of the findings. However, given the heterogeneity of reported procedures, further studies may seek to stratify results by type and severity of procedure.

Click to read the study in The Lancet

Relevant reading: Prescribing opioids after surgery in the United States, Canada and Sweden

In depth [systematic review and meta-analysis]: Original research articles published between January 1, 1990 and July 8, 2021 were reviewed for eligibility. Included were randomized controlled trials ( RCTs ) evaluating opioid analgesia versus non-opioid analgesia in surgical patients aged 15 years and older. A total of 1669 reports were assessed of which 47 (6607 patients) were included in the systematic review. The primary endpoint of self-reported pain on day 1 of discharge was comparable in the opioid and non-opioid groups (weighted mean difference [WMD] 0.01 cm, 95% confidence interval [CI] -0.26 to 0.27). The most frequent adverse effects associated with the use of opioids were vomiting (relative risk [RR] 4.50, 95% CI 1.93-10.51), nausea and constipation. Opioid use was not correlated with dissatisfaction with pain management (RR 1.14, 95% CI 0.67-1.94) or resource use health care (RR 0.88, 95% CI 0.30-2.61). The most prescribed opioids were codeine (43%), hydromorphone (23%), and tramadol (19%), with an average oral morphine equivalent of 27. Overall, the results of this study suggest that opioid use does not reduce pain and increases adverse events compared to non-opioid analgesia.

Picture: PD

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