Opioids
Maria G. Tanzi, PharmD
One in five patients continue to use opioids for longer than 3 months after a total hip or knee arthroplasty, according to results of a new analysis published in the American Journal of Health-System Pharmacists (AJHP).
“The duration and continued use of opioids during the postsurgical period, rather than the prescribed dose, have been shown to be most strongly associated with an increased rate of misuse,” said Suzanne Amato Nesbit, PharmD, BCPS, CPE, FCCP, in an accompanying editorial published in AJHP.
Data
Researchers from Australia conducted a systematic review and meta-analysis of studies in adults who underwent total hip or knee arthroplasty with at least 3 months of postoperative follow-up included. A total of 30 studies were included, with 17 reporting outcomes in those undergoing total hip arthroplasty and 19 reporting on those undergoing total knee arthroplasty, with some studies reporting on both.
The analysis showed that approximately 20% of patients had persistent opioid use for longer than 3 months postoperatively, and their use was sustained for over 12 months postoperatively. Continued use was more common in those who were opioid-tolerant compared with those who were opioid-naïve.
Practice recommendations
Multiple best practice recommendations have been published on the appropriate use of opioids in surgical patients. Current postoperative acute pain guidance has focused on using a multimodal analgesia strategy and prescribing the lowest effective opioid doses for the shortest duration of time.
The Michigan Opioid Prescribing Engagement Network discussed some of the following treatment recommendations for the management of acute pain associated with surgery:
- Opioid prescriptions intended to be used in the postoperative period should not be written prior to the date of surgery.
- The prescription drug monitoring program should be assessed prior to prescribing controlled substances in schedules 2 to 5.
- Nonopioid therapies (e.g., acetaminophen, ibuprofen) should be encouraged as the primary treatment for pain management.
- Opioids should not be prescribed with other sedative medications (e.g., benzodiazepines).
- Short-acting opioids (e.g., hydrocodone, oxycodone) should not be prescribed for more than 3- to 5-day courses.
- Fentanyl or long-acting opioids, such as methadone or oxycontin, should not be prescribed to opioid-naïve patients.
- Consider offering a naloxone coprescription to patients who may be at an increased risk for overdose.
- Extensively educate patients on safe opioid use (see more below).
Patient counseling
Patient education is essential to ensure appropriate pain management postoperatively. Some educational pearls include setting appropriate expectations, reinforcing the role of nonopioids, discussing the safe and appropriate use of opioids, and reviewing proper storage and disposal of these medications.
Educate patients on what to expect regarding their recovery and pain management goals, as some pain may be normal. Inform them that pain generally subsides over time, and patients should feel better as they continue to heal.
Also, encourage patients to use nonopioid treatments such as acetaminophen or ibuprofen for pain control, and review the role of other nonpharmacologic treatment modalities such as ice, elevation, and physical therapy. Patients should be educated on proper tapering of opioids as the surgical pain resolves and understand that prescribed opioids are only to be used for the management of their postsurgical pain and should not be taken to treat pain from other conditions. They should also be aware of the potential risks of opioids, such as their addictive properties and the likelihood for misuse and overdose. Pharmacists can also educate patients on proper and safe storage of opioids in the home.
For example, encouraging patients to place any opioid medications in a locked cabinet, lockbox, or other location where others can’t easily access these medications. When disposing of unused opioids, these medications should be taken to an approved drug take back location, like a police station or pharmacy, if possible, for proper disposal.
Leadership
Just as pharmacists took a lead role in antibiotic stewardship, pharmacists are well poised to take the lead on opioid stewardship. “Pharmacists should support the use of multimodal analgesia; provide guidance on appropriate opioid dosing, duration, and tapering; assist in universal opioid risk screening; and educate patients on safe use, storage, and disposal of opioids,” wrote Nesbit, a clinical pharmacy specialist in pain management and palliative care at the Johns Hopkins Hospital. ■