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Opioid Reduction Strategy Backfires – reduced opioid use during surgery leads to increased opioid use and increased rates of chronic pain

In recent years, as part of the fear campaign against the use of opioids in pain management, there has been a push to use less, or even no, opioids for pain relief post- surgery.  Non-opioid medications, such as paracetamol (Tylenol) and non-steroidal anti-inflammatories are being used more and more, even for major, invasive surgeries, and patients are suffering terrible, untreated pain. 

There is plenty of research to show that untreated acute pain leads to chronic post-surgical pain, yet this is being ignored, as some misguided doctors pride themselves on ‘opioid sparing’ regardless of patient wishes.  Social media is awash with patients telling their stories of untreated pain and traumatic surgeries with terrible outcomes that needn’t have occurred.  Hopefully those doctors will read this study, published recently in Jama Surgery.

Researchers at Massachusetts General Hospital (MGH) analysed the records of over 61,000 patients who underwent surgery while under general anaesthesia.   What they found, is exactly what anyone with common sense would expect to find; patients who received intraoperative opioids were less likely to feel post-operative pain and required less opioids overall during their recovery period.

The study examined the outcomes of surgical patients who received two commonly used opioids, fentanyl and hydromorphone. The patients who received the opioids experienced reduced pain levels, lower rates of continued opioid usage, and fewer refills of opioid prescriptions post-surgery. Additionally, and very importantly, the study found that these patients were less likely to develop chronic pain even after a year following the surgery.

Researchers were particularly surprised to find that patients who received higher doses of fentanyl had fewer chronic pain diagnoses post-surgery and needed fewer opioid prescriptions at the 30-day, 90-day, and 180-day marks after their surgery.  Additionally, they found that higher fentanyl administration was associated with reduced length of hospital stay and reduced rate of 30-day readmissions with no increase in adverse effects.

This study shows that contrary to the current prevailing beliefs that reducing opioid use during surgery leads to better outcomes, the reverse is true.  In fact their conclusion reads:

“Contrary to prevailing trends, reduced opioid administration during surgery may have the unintended outcome of increasing postoperative pain and opioid consumption. Conversely, improvements in long-term outcomes might be achieved by optimizing opioid administration during surgery.”

Further, the researchers wrote:

“We were surprised by the extent to which intraoperative administration of opioids was associated with medium- and long-term outcomes. This may relate to the fact that if inadequate amounts of opioids are administered in the operating room, patients may emerge from general anaesthesia in pain, a phenomenon that has a known association with persistent postsurgical pain.”

Its important to note that only fentanyl was associated with these improved outcomes, that may not be true for hydromorphone.   And the study had other limitations, including:

Because the study data was derived from patients at a single medical centre, the findings may not be generalisable, and the study was limited by the low proportion of patients from various racial and ethnic groups.  The researchers also state that while the study took steps to minimize potential biases, there may still be some lingering factors that could impact the results. The association between higher hydromorphone exposure and negative long-term outcomes should be considered with caution, taking into account the possibility of other factors not fully accounted for in the analysis.

However, this study is strong evidence that opioid-sparing during surgery, leads to poorer outcomes for patients and actually causes exactly what surgeons were hoping to avoid – increased opioid use after surgery, worse post operative pain and increased occurrences of chronic post-surgical pain.  It underscores the importance of ensuring that patients do not wake from surgery in severe pain, and that post operative pain must be properly treated to avoid persistent surgical pain and much increased opioid use.

Now lets hope that surgeons read this study in JAMA and stop torturing patients by denying surgical patients proper pain relief with the safest and most effective pain medicines available – opioids.

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