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Postoperative opioids are no better for pain relief and cause more adverse effects than nonopioids
Clinical Question
Are postoperative opioids more effective than nonopioids in reducing pain after minor or moderate surgical procedures?
Bottom line
In this well-done systematic review, opioids for managing postoperative pain following minor or moderate surgery were no more effective than nonopioids and caused more adverse effects. None of the studies included major or complex procedures, so the jury is still out for those, but the preponderance of recent data suggest that the verdict is unlikely to be much different. (LOE = 1a-)
Overuse alert: This POEM aligns with the Canadian Association of General Surgeons’ Choosing Wisely Canada recommendation: Prolonged use of opioid analgesia beyond the immediate postoperative period or other acute pain episode is not recommended. The Opioid Wisely campaign provides recommendations and tools for reducing unnecessary opioid prescribing.
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Government
Setting: Various (meta-analysis)
Synopsis
These authors searched several databases, registries, and conference proceedings to identify randomized trials that evaluated multiple doses of opioids and nonopioids in the management of postoperative pain in adolescents and adults. They excluded single-dose studies because those have been extensively evaluated — and because single doses don’t really reflect the real-world needs of patients. Two investigators independently used the Cochrane risk of bias tool to evaluate the methodologic quality of the included studies. Ultimately, the authors included 47 trials with 6607 participants (59% women) and a median duration of 7 days. The venues for the surgeries were evenly split between outpatient clinics (n = 23) and hospital operating rooms (n = 24). Only 7 studies involved surgeries that required an overnight stay. Thirty studies evaluated patients undergoing minor surgical procedures and 17 evaluated patients undergoing moderate surgeries; none evaluated patients having major or complex procedures. Finally, all the studies evaluated elective procedures; no study reported the inclusion of emergency or urgent procedures. Overall, most of the studies were of moderate to high risk of bias. Although there was a moderate degree of heterogeneity in the data, opioid-based pain management was no better than nonopioid pain management at decreasing pain on the first postoperative day or at any other subsequent point during follow-up. Vomiting occurred more frequently in patients who received opioids (11.0% vs 1.3%; number needed to treat to harm [NNTH] = 11; 95% CI 9 - 13), as did a variety of other adverse events, including a composite of vomiting, nausea, constipation, dizziness, and drowsiness (37.0% vs 23.1%; NNTH = 8; 6 - 10).
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Opiate use
I understand where this information is coming from and though not a big opiate prescriber I find that in some of my patients with OA and unable to take NSAID's that a small amount of codeine will tide them through sleepless nights. Are we going so far the other direction now that we are depriving people of pain relief?
Good review
Excellent information. Able to use non-opiods for minor-moderate day surgery cases. Excellent for patients with a history of narcotic abuse.
opioids vs non-opioids post operatively
It would be helpful to have a definition of "moderate" vs "major" surgery. I.e. Would the studies include hip replacement or laparoscopic surgery?
NSAIDs are as good as opioids in analgesia with avoiding the
.