If you use opioids pre-op...
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Background
There is insufficient prospective evidence regarding the relationship between surgical experience and prolonged opioid use and pain. The authors investigated the association of patient characteristics, surgical procedure, and perioperative anesthetic course with postoperative opioid consumption and pain 3 months postsurgery. The authors hypothesized that patient characteristics and intraoperative factors predict opioid consumption and pain 3 months postsurgery.
Methods
Eleven U.S. and one European institution enrolled patients scheduled for spine, open thoracic, knee, hip, or abdominal surgery, or mastectomy, in this multicenter, prospective observational study. Preoperative and postoperative data were collected using patient surveys and electronic medical records. Intraoperative data were collected from the Multicenter Perioperative Outcomes Group database. The association between postoperative opioid consumption and surgical site pain at 3 months, elicited from a telephone survey conducted at 3 months postoperatively, and demographics, psychosocial scores, pain scores, pain management, and case characteristics, was analyzed.
Results
Between September and October 2017, 3,505 surgical procedures met inclusion criteria. A total of 1,093 cases were included; 413 patients were lost to follow-up, leaving 680 (64%) for outcome analysis. Preoperatively, 135 (20%) patients were taking opioids. Three months postsurgery, 96 (14%) patients were taking opioids, including 23 patients (4%) who had not taken opioids preoperatively. A total of 177 patients (27%) reported surgical site pain, including 45 (13%) patients who had not reported pain preoperatively. The adjusted odds ratio for 3-month opioid use was 18.6 (credible interval, 10.3 to 34.5) for patients who had taken opioids preoperatively. The adjusted odds ratio for 3-month surgical site pain was 2.58 (1.45 to 4.4), 4.1 (1.73 to 8.9), and 2.75 (1.39 to 5.0) for patients who had site pain preoperatively, knee replacement, or spine surgery, respectively.
Conclusions
Preoperative opioid use was the strongest predictor of opioid use 3 months postsurgery. None of the other variables showed clinically significant association with opioid use at 3 months after surgery.
Editor’s Perspective
What We Already Know about This Topic
- Opioid exposure at the time of surgery has been identified as a risk factor for persistent opioid use
- Most data examining this association are based on healthcare utilization claims with limited clinical detail, particularly regarding the patient’s experience of pain
What This Article Tells Us That Is New
- In these prospectively collected cohort data, preoperative opioid use was identified as the strongest risk factor for opioid use at 3 months postoperatively
- No correlation was found between persistent opioid use at 3 months and surgical site pain at 3 months
- No association was identified between preoperative anxiety, preoperative depression, or surgery type and opioid use at 3 months in multivariable models, although credible intervals were large for some variables
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But how effective is it at high levels of pain?
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@Jolly said in If you use opioids pre-op...:
But how effective is it at high levels of pain?
You'd be surprised. When Mrs. George had her total hip (or was it the shoulder?) done, she was on a regimen of 1000mg q6h. It was remarkably effective and really decreased the need for opiates.
In the early 2010's, intravenous acetaminophen (Ofirmev) was being touted as the breakthrough in intra-op and post-op analgesia. The dose was one gram, intravenously, every 6 hours. No more than that, because your liver would fall out, of course. When I gave it IV, I could tell, within minutes, that the "feel" of the anesthetic changed. I'd need to dial down the gas. Heart rate and BP fluctuations leveled out, and I needed less narcotic during and immediately post-op. Now, my experience, is of course, anecdotal but supported by various studies.
Then...the bean counters came and decided that it was too expensive, despite the fact that opioid-related complications were reduced, and, in some cases, hospital stay was shorter. So, it was taken off the formulary. At The University, when D4 needed surgery for a bowel obstruction, I asked the surgeon about IV acetaminophen, and he told me that only the chest-cutters were allowed to use it because of expense.
Then...the scientists came and started looking at other things. Specifically, the dose we used to give, orally (325-500 mg) was too small to be really effective. If you bump it up to a gram, the change is dramatic. And, as a matter of fact, a gram orally was just as effective as a gram intravenously. So, the use of IV acetaminophen has died off, but it remains a great addition to the armentarium. It can be combined with NSAIDs and opioids. The cocktail really works.
I'd love to hear @bachophile 's experience, since he's still in the trenches with this stuff.
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we use a lot IV acetaminophen . also a lot of perioperative blocks to reduce the need for analgesia post op.
we r careful with opioids....and we basically rely on the pain service for people who need ongoing stuff. they just write in the orders, so the surgeons are a little less involved in that.
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we use a lot IV acetaminophen . also a lot of perioperative blocks to reduce the need for analgesia post op.
we r careful with opioids....and we basically rely on the pain service for people who need ongoing stuff. they just write in the orders, so the surgeons are a little less involved in that.
@bachophile said in If you use opioids pre-op...:
we use a lot IV acetaminophen
When it first became available, as I said, I was amazed at how well it worked. Then, bean counters...
https://www.mypcnow.org/fast-fact/oral-vs-intravenous-acetaminophen/
Cost: IV acetaminophen costs more than 20 times the equivalent dose of oral acetaminophen. Therefore, there is controversy whether IV acetaminophen is a cost-effective analgesic.
Summary: IV acetaminophen has only been evaluated in a perioperative setting, which limits its extrapolation to other clinical settings. Even in the post-operative period, IV acetaminophen has not shown clinical superiority; hence, the increased cost of IV acetaminophen may outweigh any benefit it offers. Until further investigation shows otherwise, IV acetaminophen may be best reserved for clinical settings where GI absorption is compromised or the use or the use of reasonable therapeutic alternatives such as NSAIDS and opioids may be undesirable.
https://pubmed.ncbi.nlm.nih.gov/26157186/
Conclusions: For patients who can take an oral dosage form, no clear indication exists for preferential prescribing of IV acetaminophen. Decision-making must take into account the known adverse effects of each dosage form and other considerations such as convenience and cost. Future studies should assess multiple-dose regimens over longer periods for patients with common pain indications such as cancer, trauma, and surgery.
Just to satisfy my curiosity, why is IV acetaminophen being used? I get it, that in some cases, oral administration is impractical or contraindicated, but otherwise?
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i see it hanging during surgery and the pacu
once a patient is on PO meds, thats a different story
" IV acetaminophen may be best reserved for clinical settings where GI absorption is compromised " which in general surgery is just about everyone
