Opioids and acute pain management

The treatment of acute pain is essential to facilitate recovery from surgery and trauma by enabling early mobilisation and reducing the risks of complications including venous thromboembolism, pulmonary embolism, pressure sores and pneumonia. 1

Severe untreated acute pain may also predispose to the development of chronic post-surgical pain or chronic pain post trauma.

Opioids remain important in the treatment of moderate to severe acute pain. 

Opioids should always be used as part of a multimodal and multidisciplinary approach. Paracetamol, NSAIDS and local anaesthetics should also be used if there are no contraindications.  Psychological interventions and the allaying of anxiety can reduce pain in this context. Non pharmaceutical methods e.g., ice, rest, heat, TENS should be considered where appropriate. 2,7

NSAIDS, gabapentin, pregabalin, systemic lidocaine and ketamine are opioid sparing and reduce opioid related adverse events.  3

Evidence-based, procedure-specific analgesic techniques should be used when evidence is available, for example PROSPECT (Procedure specific analgesic techniques) recommendations for analgesia.  6,7

Avoid modified release opioids for the treatment of acute pain. Modified release opioids confer no benefit in the management of post operative pain and have a higher risk of opioid induced adverse events including OIVI (opioid induce ventilatory impairment). The prescribing of modified release opioids is a risk factor for the development of persistent post operative opioid use (opioid use more than three months after surgery or trauma). 4,5,6,7 

Age, rather than weight, is a better determinant of the dose of opioid needed. Dose requirements decrease 2-4-fold as age increases.8,9 

Acute pain management should be individualised with regular assessments of the adequacy of analgesia and documentation of any adverse events. Inpatient pain teams should be involved in the care of any patient with difficult to manage pain.2.

The efficacy of analgesia should not be assessed using a numerical pain score in isolation.  Patients should also have their function assessed for example with the Function Activity Score (FAS). Overreliance on a unidimensional pain score may lead to overuse of opioid analgesia.10 

OIVI describes the adverse effects of opioids on breathing, and is defined by respiratory depression, raised PaCO2, decreased consciousness level and airway obstruction.  These can be fatal.  Respiratory rate alone is a poor predictor of OIVI.  Sedation is a far better predictor.  Concurrent gabapentinoid use can increase the risk of OIVI. 11,12

Opioid doses should always be titrated to effect, with the lowest effective dose for no longer than the expected duration of pain severe enough to require opioids. 7

Patients started on opioids should be given verbal and written information, this should include discussion around:

  • The risks and benefits of opioid analgesia.
  • A plan to deescalate and stop opioids once the acute phase is over.
  • Driving and opioids.
  • The safe storage and disposal of medication.

An example of written information is the British Pain Society Managing pain after surgery leaflet. 

 

There is evidence that preoperative education is associated with reduced opioid use and reduced pain intensity post operatively.7,13, 14 

While taking opioids the patients should be assessed regularly for opioid related harm.

Patients discharged on opioids should be prescribed no more than 5-7 days medication depending on the surgical procedure.  Primary care should be informed that this is an acute prescription and not to continue opioids without review.  The discharge letter must explicitly state the recommended opioid dose, amount supplied and planned duration of use. 6, 15

Patients transitioning from acute to chronic pain, who are requiring opioids, should be managed as per FPM guidance on the management of chronic pain. 

There will be a subset of patients with acute pain that have pre-existing chronic pain.  If they are coming for elective surgery consider optimising management of pre-operative pain and psychological risk-factors before admission, including weaning of opioids where possible.6

 

References:

  1. Deyo RA, Hallvik SE, Hildebran C, et al. Association between initial opioid prescribing patterns and subsequent long-term use among opioid-naïve patients: a statewide retrospective cohort study.  Journal of General Internal Medicine 2017
  2. Royal College of Anaesthetists “Guidelines for the Provisional of Service: Chapter 11 Inpatient Pain”. https://rcoa.ac.uk/sites/default/files/documents/2022-02/GPAS-2022-11-PAIN.pdf#:~:text=4-,Training%20and%20education,delivered%20by%20appropriately%20trained%20individuals.
  3. Australian and New Zealand College of Anaesthetics and Faculty of Pain Medicine. Position statement on the use of slow-release opioid preparations in the treatment of acute pain, 2018. https://www.anzca.edu.au/getattachment/558316c5-ea93-457c-b51f-d57556b0ffa7/PS41-Guideline-on-acute-pain-management
  4. Centre for Perioperative Care statement endorsed by the RCoA and FPM on the use of modified released opioids 2023.  https://cpoc.org.uk/sites/cpoc/files/documents/2023-05/CPOC%20MR%20Opioid%20statement.pdf
  5. Levy N, Mills P. Controlled-release opioids cause harm and should be avoided in management of postoperative pain in opioid naïve patients. British Journal of Anaesthesia. 2019 Jun 1;122(6):e86-90.
  6. Wilkinson, P., Srivastava, D., Bastable, R., Carty, S., Harrop‑Griffiths, W., Hill, S., Levy, N. and Rockett, M., 2020. Surgery and opioids: best practice guidelines 2021. Available from https://fpm.ac.uk/media/2721
  7. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recommendations and Reports. 2022 Nov 4;71(3):1-95
  8. Macintyre PE & Upton R (2008b) Acute pain management in the elderly patient. In: Clinical Pain Management: Acute Pain 2nd edn.
  9. Macintyre PE & Jarvis DA (1996) Age is the best predictor of postoperative morphine requirements. Pain 64(2): 357–64.
  10. Levy N, Sturgess J and Mils P.“Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: Why? British Journal of Anaesthesia 120 (3): 435e438 (2018)
  11. Macintyre PE, Loadsman JA & Scott DA (2011) Opioids, ventilation and acute pain management. Anaesth Intensive Care 39(4): 545-58.
  12. Gupta K, Nagappa M, Prasad A, et al. Risk factors for opioid-induced respiratory depression in surgical patients: a systematic review and meta-analyses. British Medical Journal Open 2018; 8
  13. Ilyas AM, Chapman T, Zmistowski B, Sandrowski K, Graham J, Hammoud S. The effect of preoperative opioid education on opioid consumption after outpatient orthopedic surgery: a prospective randomized trial. Orthopedics 2021;44:123–7
  14. Paskey T, Vincent S, Critchlow E, et al. Prospective randomized study evaluating the effects of preoperative opioid counseling on postoperative opioid use after outpatient lower extremity orthopaedic surgery. J Surg Orthop Adv 2021;30:2–6
  15. N.Levy, J.Quinlan, K.El-Boghdadly et al. An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia 2021, 76(4); 433-580

 

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