Opioid Cessation Prior to Surgery?

Does Opioid Cessation Prior to Surgery Help or Hurt? – April 4, 2017 By Thomas G. Ciccone

Patients receiving opioids prior to elective abdominal surgery had slightly longer hospital stays and were at higher risk of being discharged to a rehabilitation facility than opioid-naïve patients, according to the results of a new study.

“Chronic opioid use complicates management following surgery, and increases postoperative healthcare utilization and costs independent of other risk factors.”

None of these studies consider that opioids are prescribed for severe pain. Severe pain before surgery or unsuccessful surgery is what affects continuing opioid use.  

Therefore, developing preoperative interventions that focus on opioid cessation and alternative pain treatment prior to elective surgery may improve the quality of surgical care delivered in the United States,” the authors concluded.

However, several pain specialists questioned these conclusions.

“It is unrealistic to get somebody off opioids before surgery if they are on anything more than a minor dose,” Jennifer P. Schneider, MD, PhD, a physician certified in Internal Medicine, Addiction Medicine, and Pain Management, told Practical Pain Management. For patients taking small doses of opioids, it is much easier to do, but for patients taking significant amounts opioids, the cessation process will take more time, ideally months, she noted.

“It is not a practical thing, and one thing you can be sure of is if you start [opioid cessation] prior to surgery, it’s going to disrupt that person’s life.”

Patients will have to start a serious tapering process in the lead up to surgery. Subsequently, those patients will be at risk of developing more severe pain and loss of function than when they were on the medication, she noted.

Also, most patients would not be interested in tapering off their opioids prior to surgery, Dr. Schneider pointed out, especially if those opioids have enabled them to maintain a level of functioning in their daily lives.

Patients taking chronic opioids typically will require more analgesia for their acute recovery. These higher dose levels can increase the risk for opioid-induced adverse effects,

Dr. Wellisch also noted that pain specialists typically will not choose to take patients off their opioid medications in preparation for surgery.

However, doctors can refrain from increasing opioid dosage prior to surgery, or even pull back the dosage somewhat in order to increase the patient’s sensitivity to opioids in the acute phase of their recovery.

Dr. Schneider questioned the strength of the study’s conclusions, noting that

the data did not provide any indication of

  • pain severity,

  • disease status, or

  • level of functioning,

which could have helped explain why those patients were prescribed opioids or why they required longer hospital stays or rehabilitation following surgery.

Thank you, Dr. Schneider for pointing out the obvious: Instead of talking about opioid doses, they should be talking about pain levels, which prompt those prescriptions.

This is like talking about the evils of corticosteroids without recognizing that they provide the only possible relief for many medical conditions.

The study also found that if patients suffered from any comorbid psychological conditions, including depression, anxiety, and substance use disorder, outcomes were worse.

“If patients with more comorbidities and psychological problems go into surgery, they are more likely to have longer hospital and readmissions stays than their healthier counterparts, regardless of opioid usage,” said Jeffrey Gudin, MD, director of Pain Management and Palliative Care at Englewood Hospital and Medical Center in Englewood, New Jersey.

Chronic pain could be one of these comorbidities. All these studies act as though prescribed opioids were independent of a cause, which is pain.

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