The postoperative patient should have the right to as pain-free recovery as is possible. Apart from the obvious decrease in suffering, analgesia has the benefits of improving recovery as coughing and mobility are facilitated. Hence, hospital stay may be reduced and costs minimised.
At present, the relief of postoperative pain is not particularly well handled. One survey revealed that 94% of patients described their postoperative experiences as moderately or very painful.
A Joint Working Party of the Royal Colleges of Surgeons and Anaesthetists, amongst other points, recommended:
- improvements in hospital staff education and attitudes to postoperative pain relief
- the responsibility for analgesia should be the task of one named member of staff who should set up an acute management team
In the UK, the indication for the treatment of post-operative pain has been removed from the licences of all prolonged release opioids due to the increased risk of persistent post-operative opioid use (PPOU) and opioid-induced ventilatory impairment (OIVI) (1):
- PPOU is defined as continued opioid use beyond 90 days from the day of operation
- evidence from across the EU including the UK has shown that the incidence of PPOU ranges from 2% - 44% in patients treated with prolonged-release opioids
- note that PPOU is more prevalent (incidence up to 60%) in patients taking prolonged-release opioids pre-operatively
- respiratory depression is also a well-known side effect of opioids, especially if taken in excess or in combination with other sedating medicines (for example benzodiazepines), pregabalin or gabapentin) which can lead to coma and potentially death (1):
- OIVI is a serious form of respiratory depression associated with:
- depression of respiratory rate and/or depth of breathing – ‘central respiratory depression’
- depression of consciousness – ‘sedation’
- depression of supraglottic airway muscle tone – ‘upper airway obstruction’
- reported incidence of OIVI is difficult to determine, although the international multidisciplinary consensus statement quotes an incidence of OIVI ranging from 0.4% to 41% depending on the identification measures
It is not recommended to use transdermal patches for the treatment of post-operative pain (2).
Advice for Healthcare Professionals (2):
- prolonged-release opioids provide relief from chronic severe pain, however, they should not be used for the treatment of acute pain following surgery
- prolonged-release opioids are associated with an increased risk of PPOU characterised as continued opioid use beyond 90 days following the operation, and an increased risk of OIVI causing serious respiratory depression, sedation, and depression of upper airway muscle tone
- before surgery, discuss with the patient the following:
- explain the risks of PPOU, dependence and potential risk of addiction and withdrawal reactions
- explain the risk of OIVI especially for patients with underlying respiratory conditions
- immediate-release opioids are used for short-term treatment of pain
- discuss with the patient pain management strategies involving the use of immediate-release opioids and multimodal analgesia and plan for end of treatment
- patients whose pain is managed with opioids pre-operatively should have their treatment reviewed before and after surgery in line with Consensus Best Practice Guidelines
- at discharge from hospital:
- only prescribe and supply a sufficient amount of immediate-release opioids to treat acute post-operative pain to minimise the risk of PPOU, dependence, stock piling of unused opioids and potential for diversion
- communicate the pain management plan with the primary care practice taking over care in the community and document in patient clinical notes
- it is important to report suspected dependence or respiratory depression to any medicine, including an opioid, via the Yellow Card Scheme
Reference:
- MHRA Safety Update volume 18, issue 8: March 2025: 1