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Waiting for Surgery: Opioids at the Forefront, Again!

April 3, 2021 | Article No. 39

Waiting for Surgery: Opioids at the Forefront, Again!

April 3, 2021 | Article No. 64

Contributors

Ayesha Siddiqua MSc, PhD

Mohit Bhandari MD, PhD

Insights


  • The COVID-19 pandemic has created a large backlog of elective surgeries that will take years to get through.

  • Delaying surgeries does not delay the prognosis of disease nor the associated pain.

  • The experience of pain can be exacerbated through pain catastrophizing during a pandemic.

  • Patients may have challenges coping with pain while awaiting surgery, which may prompt the prescription and prolonged use of opioids.

  • Prolonged use of opioids can not only lead to addiction but also compromise future postoperative outcomes.

  • Instead of increased reliance of opioids, clinicians need to consider a broad range of therapeutic options for safe and effective pain management to not exacerbate the current opioid crisis.


“Knee replacement. Cancer surgeries. Organ transplants. Worldwide, tens of millions of elective surgeries have been postponed because of the coronavirus. Public health officials have had to balance patients’ urgent need for treatment against the very real danger of potentially immune-compromised individuals being exposed to the virus in a hospital setting, and the need to reserve hospital capacity for COVID-19 patients.”
“But the decision to postpone these so-called elective surgeries may have severe consequences—including deepening the opioid crisis. Based on what we already know about the connection between preoperative pain management and opioid dependency, the coronavirus pandemic is creating a perfect storm.”

Asar (2020) (1)

Since the beginning of the COVID-19 pandemic, the global scientific community has largely focused on the study of SARS-CoV-2, as well as ways to prevent the infection and treat the disease resulting from this virus. There is no doubt in the importance of setting these research priorities – as of March 30, 2021, 127,987,404 cases and 2,797,124 deaths  related to COVID-19 have been reported globally. While the immediate health consequences of the pandemic have been reported the most in the media, there have been many secondary epidemics resulting from the spread of SARS-CoV-2 that either do not meet the eyes or receive the attention they deserve. These secondary epidemics include – but are not limited to – the vast range of negative consequences of the pandemic for the personal, social, and economic well-being of populations around the world (see our OE Insight “Impact of COVID-19 Lockdowns in the Developing World: A Humanitarian Crisis Like No Other” for details ). In addition to causing new epidemics, the pandemic has also exacerbated previous epidemics. This includes the opioid crisis, which has been growing momentum throughout the course of the past year, and has significant implications for the management of patients waiting for surgery. Since the beginning of the pandemic, elective surgeries have been cancelled around the world – with no certainty regarding when they will be resumed again. Our previous OE Insights “A Surgical Deep Freeze: Backlogs, Burden, and New Beginnings” and “COVID-19 and Surgery: Are We Trading One Problem for Another?”  provide an overview of the many challenges health systems can expect to experience as they manage and catch up with the backlog of surgeries. Our OrthoEvidence model from earlier in the pandemic shows that waitlists can grow to 7 times pre-pandemic numbers . Yet, as we are all aware, just because surgeons stop operating, diseases do not stop progressing. As patients wait for surgeries longer and longer, they may experience levels of pain that are no longer tolerable which may lead to the prescription, use, and ultimate dependance on opioids. Not only can dependence on opioids compromise post-operative outcomes, they are also not the safest therapeutic option given their addictive nature. In a future that is riddled with many unknowns, there have been calls to implement alternative strategies to manage pain in patients awaiting surgery – with no end in sight regarding when their lucky day will be. 


“Many of us try opioids, which are often used for moderate to severe pain. But that risks turning even more people into statistics in North America’s raging addiction crisis. Opioids were a factor in two-thirds of America’s 72,000 drug overdose deaths in 2019.”

Stauffer (2020) (2)

“An estimated 20% of patients presenting to physician offices with noncancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription.”

Centers for Disease Control and Prevention (2016) (3)

First Things First: A Brief Primer on Opioids

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Opioids refer to a class of drugs that provide relief from pain. Opioids are available as both prescribed medications (i.e., painkillers) and street drugs (e.g., heroin). Prescription opioids are typically used to treat moderate to severe pain (4). Opioids can become addictive as they can make people feel relaxed, happy, or “high” (4). Opioids do not fall in the same category as over-the-counter painkillers (e.g., Aspirin and Tylenol). Below is a list of common drug and brand names of opioids. 

Exhibit 1: Common drug and brand names of prescription opioids (4)


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Common drug names of opioids Brand names of opioid
Oxycodone OxyContin, Roxicodone, Oxecta, Oxaydo, Xtampza ER, Percodan, Targiniq, Xartemis XR, Oxycet, Roxicet, Tylox, Percocet
Hydrocodone-Acetaminophen Vicodin, Norco, Lorcet, Zamicet, Verdrocet, Lortab, Anexsia, Co-Gesic, Hycet, Liquicet, Maxidone, Norco, Xodol 10/300, Zolvit, Zydone
Hydrocodone bitartrate Sysingla, Zohydro ER
Hydrocodone-Homatropine Hycodan, Hydromet
Hyrdocodone-Ibuprofen Ibudone, Xylon 10, Reprexain, Vicoprofen
Pseudoephedrine-Hydrocodone Rezira
Rezira Vituz
Hydrocodone-Cpm-Pseudoephed Zutripro
Morphine Duramorph, Infumorph P/F, MS Contin, Oramorph SR, Avinza, Arymo ER, Kadian, Morphabond, Roxanol-T
Morphine-Naltrexone Embeda
Hydromorphone Dilaudid, Exalgo, Palladone
Fentanyl Cirtrate Actiq, Fentora, Abstral, Lazanda, Onsolis, Sublimaze
Fentanyl Duragesic, Subsys
Codeine Poli-Chlorphenir Poli Tuzistra XR
Acetaminophen with codeine phosphate/Acetaminophen-Codeine N/A
Methadone Dolophine, Methadose
Methadone Hydrochloride Methadose
Morphine Sulfate Morphabond
Oxymorphone Hydrochloride Opana
Meperidine Demerol
Tramadol N/A
Carfentanil N/A
Buprenorphine Subatex, Buprenex, Butrans, Probuphine

 

Opioid use comes with some serious risks, including the likelihood of overdose and opioid use disorder (3). Regular use of these drugs can increase an individual’s tolerance and dependence, which can lead to the need for higher and more frequent doses (4). Opioid use disorder is characterized by a problematic pattern of opioid use, which can cause clinically significant impairment or distress (3).  Individuals with this disorder have a difficult time cutting down and controlling the use of opioids and experience challenges in fulfilling their obligations at work, school, or home (3). Many guidelines have been developed for safe prescription of opioids, as a history of using opioids increases the risk for overdose and opioid use disorder (3). 


“Although opioids are not recommended as a first line of treatment for patients suffering from chronic pain conditions, their use is not uncommon in patients progressing to disease states requiring surgery. In a 34,000-patient cross-sectional study of preoperative use of opioids, it was noted that 23% of the patients scheduled for surgery and 21% of those scheduled for knee surgery reported preoperative use of opioids.”

Cisternas et al (2020) (5)

“Uninfected (with COVID-19) patients whose elective surgeries were delayed by the pandemic: This large group represents much of the surgical backlog given the duration of this pandemic. With patients apprehensive about SARS-CoV-2 exposure risks and seeking to limit their contact with the health care system, more opioids may be prescribed to avoid the need for return visits. This prescribing pattern can create a new unwanted reservoir of unused opioids within at-risk populations and trigger persistent post-operative opioid use.”

Mudumbai S et al (2020) (7)

Delaying Surgeries, Impending Pain

Patients with upcoming surgeries are often prescribed opioids to manage their pain as they wait for treatment (1). Opioids are commonly prescribed for a wide range of surgeries, including orthopaedic surgeries (e.g., hip, knee, and shoulder surgeries), neurological surgeries, and colorectal surgeries (1). Elective surgeries are not considered an emergency; however, they are still necessary. Delaying elective surgeries can leave patients in significant pain, which in turn prolongs the period of time these patients use opioids, and increases the risk of dependence on these painkillers. There is compelling evidence to support the concern regarding pre-operative opioid use – patients who use opioids before their surgery to manage pain have a 70% chance of remaining on opioids years later post-surgery (8). 

The pain patients experience while awaiting surgery may be exacerbated during a pandemic. Pain catastrophizing has been described as an exaggerated and continuous negative mental status which occurs when an actual or anticipated painful experience leads to an overvaluation of pain sensation (9). Pain catastrophizing has been associated with increases in pain perception, development of chronic pain, as well as opioid usage (9,10). The COVID-19 pandemic can increase pain catastrophizing among patients waiting for surgeries by exacerbating 3 key conditions needed for this state of mind, including (5): 




  1. Magnification – Fear that something serious will happen 

  2. Rumination – Not able to stop thinking about the pain 

  3. Helplessness – The feeling that there is no intervention available to reduce the intensity of pain 



Under normal circumstances, pain catastrophizing during short surgical delays may not be likely. However, in the context of a pandemic when there is no known date for the needed surgery, compounded by many other stressors (e.g., social isolation, lack of employment, underemployment), patients may be far more likely to engage in pain catastrophizing, which can lead to increase in opioid use. Once patients become dependent on opioids to manage chronic pain – it may not take long to develop opioid use disorder. Indeed, in one study, pain relief was reported as the primary initial reason for opioid use among 83% of patients with opioid use disorder (11). 


“Surgery represents a critical event where the majority of patients are exposed to opioids regardless of whether or not they have had a prior opioid-related adverse event including overdose. Opioid tolerant patients typically require higher doses over extended postoperative periods further compounding the risks of persistent opioid use, misuse, addiction, and overdose. Thus, tangible risks exist for both opioid-naïve and opioid-tolerant patients undergoing surgery.”

Hah et al (2018) (8)

Short Term Fix, Long Term Problems

For now, it may be tempting for clinicians to prescribe opioids to patients who are waiting for surgery to manage their pain in the meantime. While this may seem to be a pragmatic short term solution, it does not come without long term costs. Higher levels of pre-operative opioid use have been associated with increased risk of readmissions and higher healthcare expenditures after surgery (12,13). Additionally, pre-operative opioid use among patients who received total hip arthroplasty has been associated with negative post-operative outcomes including increased risk of longer hospital stay and discharge to rehabilitation facility, as well as lower patient-reported outcome scores (14). Furthermore, among patients undergoing common elective orthopaedic surgeries, those with chronic pre-operative opioid use showed increased risk of chronic post-operative opioid use – whereas not using opioids before surgery decreased this risk compared to continuous pre-operative opioid use (15). 

At a broader level, it is important to remember that opioids already remain heavily used as the primary means of post-operative acute pain management (8). Notably, over 80% of patients are prescribed opioids after low-risk surgery (16). Considering that regular use of opioids can increase an individual’s tolerance, it is possible that patients who use opioids for a long period of time to manage their pain as they wait for surgery will end up needing much higher doses to manage post-operative pain. This is particularly concerning for orthopaedic patients, as they experience a significant amount of pain with acute injuries and chronic conditions and typically require opioids for post-operative pain management (17). In the United States, orthopaedic surgeons are the third highest prescribers of opioids (18). Given the already high use of opioids in surgery and the risks associated with prolonged opioid use, using this medication as a primary means of pain management among patients who are currently waiting for surgery is the perfect formula for an opioid crisis like we have never seen before – both during and after the pandemic is over. 

 


“Patients whose surgeries have been delayed urgently need support throughout the period they’re using opioids, including pre-surgery and eventually post-surgery. They need evidence-based solutions that will help them manage their pain. For some patients, injections have enormous potential as a highly focused way to block pain receptors. For others, physical therapy or mindfulness practices can help manage pain and anxiety. A growing body of evidence shows that mindfulness can reduce chronic pain, and it’s also proven to have a significant positive impact on depression and quality of life issues. Cognitive behavioral therapy has also been proven to be effective at treating anxiety, depression, and chronic pain.”
“Doctors and surgeons still need more training in both how to manage pain and how to help patients safely taper off these medications once their surgeries have been performed. Patients need support to ensure that circumstances beyond their control don’t send them down the path to a lifelong struggle with chemical dependency.”

Asar (2020) (1)

“As well as there being evidence that the preoperative period is an ideal time to wean opioids to improve surgical outcomes, there is also increasing evidence that non-pharmacological interventions such as supervised and personalised exercise programmes are, at the very least, comparable to pharmacological interventions at relieving chronic non-cancer pain, and have additional health benefits, including increasing life expectancy. The mechanism of exercise-induced analgesia is beginning to be understood.”

Levy et al (2021) (6)

Pragmatic Pain Management: Some Tips

Instead of relying on opioids only to manage pain among patients waiting for surgery, it is important to consider the full range of pain management interventions available. Although it may be challenging to implement a wide range of pain management strategies given current service cutbacks during a pandemic, clinicians need to think beyond increased reliance on opioids for pain relief among their patients. Following are some categories of interventions that have been suggested for use (5):



1. Psychological support including counselling and mindfulness protocols 




  • Some self-regulation practices such as mindfulness meditation has shown to reduce pain. 

  • These can be performed virtually. 



2. Rigorous use of minimally interventional therapeutic approaches by using titrated dosing of nonopioids (e.g., NSAIDs, acetaminophen, gabapentin) 




  • There are specific guidelines for second-line of treatment for patients with specific conditions who fail to respond to NSAIDs and acetaminophen. For e.g., the CDC recommends the use of intra-articular administration of hyaluronic acid and a limited number of glucocorticoid injections as a second-line treatment for patients with chronic osteoarthritis. 



3.    Long-term therapeutic approaches focusing on peripheral changes in neural afferent activity that emerge from inflamed joints – which includes periarticular delivery of local anesthetics and ablating agents that target the peripheral nerve terminal. 


“…opioids should only be considered as a last resort for chronic non-cancer pain, after appropriate shared decision making, and with a deprescribing plan agreed at the initial prescription…”

Levy et al (2021) (6)

Final Words: Use Opioids with Caution

It has been more than a year since the WHO declared the COVID-19 pandemic, but the entire world continues to struggle its way out of this global health crisis. The pandemic has necessitated the health community to marshal all our resources to deal with this monumental challenge, and rightly so. However, we would be hugely short sighted to undermine the ramifications of ignoring crucial and burning health issues, such as the opioid crisis. The opioid epidemic is a result of social, economic, and personal health determinants (19), all of which are substantially and negatively impacted by the pandemic. Prescription opioids for chronic pain has played a significant role in the opioid crisis. Persistent opioid use comes with many consequences, including the potential for opioid use disorder for the patient, misuse and diversion issues for the society, and once a patient is on large doses of opioids, we face medical and ethical challenges around balancing benefits and harms (20). We cannot miss the larger perspective here – a great majority of chronic pain burden comes from musculoskeletal problems (21) that not only cause significant pain, but also reduce functional quality of life for an individual. Unfortunately, the pandemic has added further fuel by delaying elective surgeries (many of which are musculoskeletal) and created a surgical backlog like never seen before. Even patients and physicians unwilling to use opioids have fewer alternatives because of physical distancing protocols and restrictions of other services to manage pain. This is a fertile ground for physiological and psychological sensitization that amplifies the burden of pain and predisposes the patient with pain for more suffering and dependence on narcotics. In fact, the most consistently observed risk factor for prolonged opioid use, even after a successful surgery, has been the duration and quantity of pre-operative opioids (22). Until health systems consider these priorities as equally important, we run the risk of a much worse opioid crisis and chronic pain. If the waves of the opioid crisis are not tamed now, we will soon be facing a tsunami of patients with a wide range of opioid use related complications that health systems are simply not prepared to handle. It is time to take a proactive approach and begin to get in the habit of comprehensive pain management planning – the time it will cost us now is well worth the investment for a safer future. 


References

1.    Asar A (2020). Postponing elective surgeries due to COVID-19 might have pushed the opioid crisis to the next level. Retrieved from https://fortune.com/2020/08/08/elective-surgeries-opioid-crisis-coronavirus/

2.    Stauffer J (2020). Doctors and patients face a painkiller crisis, even as they fight COVID. Retrieved from https://fortune.com/2020/12/16/painkillers-hospitals-surgery-nsaids-opioids-addiction-covid/

3.    Centers for Disease Control and Prevention (2016). CDC guideline for prescribing opioids for chronic pain — United States, 2016. Retrieved from https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

4.    John Hopkins Medicine (n.d.). Opioid addiction. Retrieved from https://www.hopkinsmedicine.org/opioids/what-are-opioids.html#:~:text=Opioids%20are%20sometimes%20referred%20to,such%20as%20OxyContin%20and%20Vicodin

5.    Cisternas A et al (2020). Unintended consequences of COVID-19 safety measures on patients with chronic knee pain forced to defer joint replacement surgery. PAIN Reports 5(6): e855. DOI: 10.1097/PR9.0000000000000855

6.    Levy NA et al (2021). UK recommendations on opioid stewardship. The BMJ 372: m4901. DOI: 10.1136/bmj.m4901

7.    Mudumbai S et al (2020). Collateral Damage as Crises Collide: Perioperative Opioids in the COVID-19 Era. Pain Medicine 21(11): 3248-3249. DOI: 10.1093/pm/pnaa308

8.    Hah JM et al (2018). Chronic opioid use after surgery: Implications for perioperative management in the face of the opioid epidemic. Anesthesia & Analgesia 125(5): 1733-1740. DOI: 10.1213/ANE.0000000000002458

9.    Leung L (2012). Pain catastrophizing: An updated review. Indian Journal of Psychological Medicine 34(3): 204–17. DOI: 10.4103/0253-7176.106012

10.    Quartana PJ et al (2010). Pain catastrophizing: A critical review. Expert Review of Neurotherapeutics 9(5): 745–758. DOI: 10.1586%2FERN.09.34

11.    Weiss RD et al (2014). Reasons for opioid use among patients with dependence on prescription opioids: the role of chronic pain. Journal of Substance Abuse Treatment 47(2): 140–145. DOI: 10.1016/j.jsat.2014.03.004 

12.    Ruiqi T et al (2020). Preoperative opioid use and readmissions following surgery. Annals of Surgery. DOI: 10.1097/SLA.0000000000003827

13.    Waljee JF et al (2017). Effect of preoperative opioid exposure on healthcare utilization and expenditures following elective abdominal surgery. Annals of Surgery 265(4): 715-721. DOI: 10.1097/SLA.0000000000002117 

14.    Bryant B et al (2019). Preoperative opioid use negatively affects patient-reported outcomes after primary total hip arthroplasty. Journal of American Academy of Orthopaedic Surgeons 27(22): e1016-1020. DOI: 10.5435/JAAOS-D-18-00658

15.    Brock JL et al (2019). Postoperative opioid cessation rates based on preoperative opioid use. The Bone & Joint Journal 101-B(12): 1570–1577. DOI: 10.1302/0301-620X.101B12.BJJ-2019-0080.R2

16.    Wunsch H et al (2016). Opioids prescribed after low-risk surgical procedures in the United States, 2004-2012. JAMA 315(15): 1654-1657. DOI: 10.1001/jama.2016.0130

17.    Morris BJ & Mir HR (2015). The opioid epidemic: Impact on orthopaedic surgery. The Journal of the American Academy of Orthopaedic Surgeons 23(5): 267-271. DOI: 10.5435/JAAOS-D-14-00163

18.    Volkow ND et al (2011). Characteristics of opioid prescriptions in 2009. JAMA 305(13): 1299-1301. DOI: 10.1001/jama.2011.401

19.    Dasgupta N et al (2018). Opioid crisis: No easy fix to its social and economic determinants. American Journal of Public Health 108(2): 182-186. DOI: 10.2105/AJPH.2017.304187 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846593/

20.    Rieder TN (2020). Is nonconsensual tapering of high-dose opioid therapy justifiable? AMA Journal of Ethics 22(8): E651-657. DOI: 10.1001/amajethics.2020.651. AMA J Ethics. 2020;22(8):E651-657. doi: 10.1001/amajethics.2020.651.

21.    Blyth FM et al (2019). The global burden of musculoskeletal pain—Where to from here? American Journal of Public Health 109(1): 35-40. DOI: 10.2105/AJPH.2018.304747 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6301413/

22.    Lawal OD et al (2020). Rate and risk factors associated with prolonged opioid use after surgery: A systematic review and meta-analysis. JAMA Network Open 3(6): e207367. DOI: 10.1001/jamanetworkopen.2020.7367 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7317603/

 


Contributors

Ayesha Siddiqua MSc, PhD

Ayesha Siddiqua completed her graduate training from the Health Research Methodology Program in the Department of Health Research Methods, Evidence, and Impact at McMaster University. She is a Data Scientist at OrthoEvidence.

Mohit Bhandari MD, PhD

Dr. Mohit Bhandari is a Professor of Surgery and University Scholar at McMaster University, Canada. He holds a Canada Research Chair in Evidence-Based Orthopaedic Surgery and serves as the Editor-in-Chief of OrthoEvidence.

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