FPM/RCoA Call to Action: Perioperative Opioid Management

There is increasing public and professional concern regarding the increase in opioid prescriptions in the UK, which correlates closely with an increase in opioid-related deaths (1). The scale of the opioid crisis in the US has gained much media attention in the UK. While the cause is undoubtedly multifactorial (2-7), one recognised significant source of opioid load in the community in the US arises from continuation of opioids following surgery. While there are demonstrable gaps in our understanding of the current situation in the UK, private and published audits collectively show that opioids prescribed for surgery are frequently continued in the intermediate term in the community. There is legitimate concern that communication between hospital and community professionals is suboptimal with prescriptions or medicines unused or continued without timely reassessment. To complicate matters, some patients already take opioids before surgery while others develop chronic post-surgical pain for which continuation of perioperative opioids is rarely the preferred treatment (8). Risk areas include disproportionate opioid prescribing (9), low risk surgery (10), unused opioids (11) and certain specific types of surgery (12).

Hospital admission for surgery presents an opportunity for medicines optimisation but could lead to an unnecessary opioid load in the community without meticulous perioperative management.
All professionals must be committed to the highest standards of prescribing perioperatively, including the use of multimodal analgesia. This may include the use of opioids used in the smallest appropriate doses balancing benefits and harms. Best prescribing practice must continue during postoperative rehabilitation, which is increasingly undertaken after discharge from hospital. Making the right decision about stopping opioids is crucial.

With this backdrop in mind, the Faculty of Pain Medicine, Royal College of Anaesthetists, Royal College of General Practitioners, Royal College of Surgeons and partners, as part of a wider policy on opioids, is establishing an evidence-based clinical framework to facilitate local decision-making and policy regarding opioid management perioperatively and, most importantly, opioid prescribing following discharge. Healthcare communities must work together to drive best practice.

This aim of this communication is to promote engagement with this process.

We are seeking high quality audit reports, case studies or descriptions of local best practice including examples of coordinated professional working to inform this work.

Specifically we seek;

• Evidence of the opioid load in the community or the reasons opioids are continued.
• Practices that maximise opportunities for opioid withdrawal or reduction preoperatively or following discharge.
• Shared guidance for GP opioid prescription after surgery.

Please send this to ekato-clarke@fpm.ac.uk
. 
References

1. Overdose deaths in comparison to opioid prescription sales and opioid statistics, related treatment admissions, 1999-2010. Sources: National Center for Health Statistics, Center for Disease Control (CDC) WONDER Database 2014; DEA Automation of reports and Consolidated Order Systems; The substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Sets (TEDS).
2. Franklin GM, Mai J, Wickizer T, et al. Opioid dosing trends and mortality in Washington State workers’ compensation, 1996–2002. Am J Ind Med 2005; 48(2): 91–99.
3. Manchikanti L, Singh A. Therapeutic opioids: A ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 2008; 11: S63–S88.
4. Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-36, DHHS Publication No. SMA 09-4434). Rockville, MD, 2009.
5. Manchikanti L, Fellows B, Ailinani H, et al. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician 2010; 13: 401–443.
6. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose. Ann Intern Med 2010; 152(2): 85–92.
7. Braden JB, Russo J, Fan MY, et al. Emergency department visits among recipients of chronic opioid therapy. Arch Intern Med 2010; 170(16): 1425–1432.
8. Factsheets. Global Year against Pain After  Surgery. International Association for the study of pain. https://www.iasp-pain.org/GlobalYear/AfterSurgery.
9. Howard R, Fry B, Gunaseelan V et al. Association of opioid prescribing with opioid consumption after surgery in Michigan. JAMA Surg. Published online November 7, 2018. doi:10.1001/jamasurg.2018.4234.
10. Wunsch H, Wijeysundera DN, Passarella MA, et al., Opioids Prescribed After Low-Risk Surgical Procedures in the United States 2004-2012. JAMA; 2016; 315(15): 1654-1657.
11. Bicket MC, Long JJ, Pronovost PJ et al. Prescription Opioids Commonly Unused After Surgery A Systematic Review 2017 JAMA Surgery; 152(11): 1066-1071.
12. Sun EC, Darnall BD, Baker LC et al. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA Internal Medicine. 2016 176(9): 1286-1293.