Post-operative opioids at discharge increase adverse events without improving pain management

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

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

Evidence Rating Level: 1 (Excellent)

Study Rundown: Opioids are commonly prescribed for management of post-operative pain following major surgical procedures. However, over the last few decades, their use has become so prevalent that even minor procedures present the chance for opioid naïve patients to become opioid dependent. There is little evidence surrounding the effectiveness of opioid versus non-opioid analgesia for post-operative pain for procedures of lesser severity. This systematic review and meta-analysis aimed to compare the clinical efficacy of opioids and non-opioid analgesia for post-operative pain management. The primary outcome was self-reported pain on day 1 after discharge and vomiting up to 30 days post-discharge. According to study results, post-operative analgesia with opioids did not significantly reduce pain compared to opioid-free analgesia. In contrast, the authors found saw an increased occurrence of vomiting among the opioid-analgesia group compared to non-opioid. This study was well-designed and included randomized controlled trials from over three decades, adding to the validity of results. However, given the heterogeneity in the reported procedures, further studies may look to stratify findings based on procedure type and severity.

Click to read the study in The Lancet

Relevant Reading: Opioid Prescribing After Surgery in the United States, Canada, and Sweden

In-depth [systematic review and meta-analysis]: Original research articles published between Jan 1, 1990, and Jul 8, 2021, were screened for eligibility. Included were randomized controlled trials (RCTs) assessing opioid vs. non-opioid analgesia among surgical patients ≥15 years of age. Altogether, 1669 reports were assessed of which 47 (6607 patients) were included in the systematic review. The primary outcome of self-reported pain on day 1 of discharge was comparable in the opioid vs. non-opioid groups (weighted mean difference [WMD] 0.01 cm, 95% confidence interval [CI] -0.26 to 0.27). The most common adverse events related to opioid use were vomiting (relative risk [RR] 4.50, 95% CI 1.93-10.51), nausea, and constipation. Opioid use did not correlate with dissatisfaction with pain management (RR 1.14, 95% CI 0.67-1.94) or use of healthcare resources (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, findings from this study suggest that use of opioids does not reduce post-operative pain and increases adverse events compared to opioid-free analgesia.

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