Opioids, sometimes called narcotics, are a group of drugs which are commonly used to relieve pain. Some like morphine are extracted from the opium poppy but others like fentanyl are manufactured.
The Sumerians in Mesopotamia cultivated the opium poppy known as the joy plant in 3,400BC. In 750BC Homer in Odyssey1 suggests Helen of Troy added a drug to wine. This drug took away all pain. Marcus Aurelius, the great Roman Emperor and philosopher consumed opium daily2. Great Britain was involved in two Opium wars against the Qing dynasty of China in the nineteenth century3. One survey of US soldiers in Vietnam revealed 6% were regular users of opium4.
Today we are in the midst of an opioid epidemic. The source of the current epidemic is our healthcare system. This began with a marketing campaign targeting doctors in the United States, which claimed that the opioid oxycodone was not addictive. Before its addictive qualities became apparent, oxycodone became a very popular drug for managing post-surgical pain. It is prescribed initially in hospitals and repeat scripts are prescribed in general practice. Between 1992 and 2012 there was a 15-fold increase in opioid dispensing in Australia. During this time, opioid related hospitalizations and opioid related deaths almost doubled5. In 2016-17 3.1 million Australians had one or more prescriptions dispensed for opioids6. When the cost of the drugs is added to the cost of adverse health outcomes and time lost from work, the economic cost to the nation is enormous. The cost is estimated to be 3.4% of gross domestic product in the US7.
Culture influences prescribing pattern. 82% of patients receive opioids following surgery for hip and ankle fractures in the US compared to 6% in the Netherlands8. In the US, 87% of patients receive opioids after head and neck surgery. The number in Hong Kong is 1%9. The pattern in Australia aligns with the US. There are health and social consequences.
A report from the Queensland Clinical Senate10 identified a number of personal and public health consequences of misuse of opioids, including car accidents, falls in the elderly associated with bone fractures, immunosuppression and recurrent infections, osteoporosis and loss of the pain-relieving effectiveness of the opioids. Every day in Australia there are 150 hospitalisations attributed to opioid harm and three people die from drug-induced deaths involving opioid use6.
Around 8% of patients who have not previously received opioids and who are prescribed opioids following low risk surgery are still consuming the drug 12 months postoperatively11. For each additional week of use following surgery there is a 43% increase in misuse12. For the patients who cease the opioids soon after surgery, 80% of the prescribed pills are unused13. The unused pills are on occasions, used by people for whom they were not prescribed and also filter onto the black market.
Patients undergoing surgery have a right to good pain relief. Not only is this humane, but patients recover better from surgery with fewer complications when the pain of surgery is well controlled14. Recognizing this and the challenges of the current opioid epidemic, it is the goal of practitioners to provide good analgesia safely, both in hospital and following discharge.
A number of strategies can reduce the need for opioids. Good preparation for surgery, setting realistic expectations about discomfort and pain management is important15. It is not practical, possible or safe to have complete pain relief after surgery16. Before patients are admitted to hospital, it is possible to identify those at risk of poor postoperative pain control17. These patients benefit from the support of psychologists throughout their surgical journey. Sadly, such support is rarely available.
Simple strategies including listening to music, reading, watching a movie and the use of hot and cold packs are opioid sparing18. If medications are required, one should start with Paracetamol. This reduces the need for opioids by up to 30% particularly when combined with anti-inflammatory medication such as Ibuprofen19. If additional pain relief is required, there are a variety of opioids which can be used, some less addictive than others. The choice of the appropriate opioid for the circumstance is very important. Consequently, pain management after surgery should be monitored by one’s doctor.
Patients can contribute to reducing the impact of the current opioid crisis. If opioids have been prescribed and they are no longer required, the unused pills should be returned to the pharmacy. This eliminates the chance of their being used for unintended purposes.
Health Departments are responding to these challenges. In June this year, restrictions were imposed on the prescription of opioids in Australia by the Pharmaceutical Benefits Scheme20. These changes have caused anxiety among doctors and patients alike21. The restrictions are commendable, but the right balance needs to be found.
The causes of pain are complex22. Pain management is also complex. The focus of this paper is on acute pain, that is new pain expected to be short lived, associated with accidents and surgery. Some people suffer persistent or chronic pain like back pain or arthritis. Different strategies are available for the management of chronic pain. However, even in the setting of chronic pain, the administration of opioids must be judicious, as opioids lose their effect if taken in larger doses than required, over extended periods.
Patients can expect good pain control following surgery. This is important for a good recovery. The inappropriate prescription of opioids in recent decades has resulted in an opioid crisis impacting individuals and the wider community. It comes at a great economic cost. Measures are being taken across the health system to correct unwise practices. It will take time for the right balance between the provision of good pain control and the safety of the patient and the community to be achieved.
Written by Dr Ian Airey, who retired from medical practice in April 2020. Throughout his career he practiced in the specialties of anaesthesia and intensive care. His practice embraced both public and private practice. His last appointment was Director of Acute Care Services at Mater Health Queensland. In this role he had oversight of the Departments of Anaesthesia, Emergency Medicine and Intensive Care. Although retired from clinical practice, he maintains his membership of the Queensland Health Acute Pain Working Group. He was recently a keynote speaker in a national webinar on the opioid epidemic.
- Homer Odyssey 4. 220 – 240
- Classical Philology 1965; 60: 23-24
- Taylor Wallbank et al A Short History of the Opium Wars Hackett (1992)
- Baker SL Drug Abuse in the United States Army Bull. N.Y. Acad. Med. 1971; 47: 541-49
- Blanch B et al An overview of the patterns of prescription opioid use, costs and related harms in Australia Br J Pharmacol. 2014; 78: 1159-1166
- Opioid Harm in Australia and comparisons between Australia and Canada Australian Institute of Health and Welfare 2018
- Council of Economic Advisers. 16 Jan 2020 The Economist
- Lindenhovius A L et al Differences in Prescription of Narcotic Pain Medication after Operative Treatment of Hip and Ankle Fractures in the United States and the Netherlands J Trauma 2009; 67: 160-164
- Li R J et al Comparison of Opioid Utilization Patterns after Major Head and Neck Procedures Between Hong Kong and the United States JAMA Otolaryngol Head Neck Surg. 2018; 144: 1060-1065
- Queensland Clinical Senate The Pain of Managing Opioids: health.qld.gov.au/ clinicalpractice/ engagement/clinical-senate/default.asp
- Alam A Long-term Analgesic Use after Low-risk Surgery: A Retrospective Cohort Study Arch Intern Med 2012; 172: 425-430
- Brat Gabriel A et al Postsurgical prescriptions for opioid naïve patients and association with overdose and misuse: retrospective cohort study BMJ2018;360:j5790 | doi:10..1136/bmj.j5890
- Hill MV Educational Intervention Decreases Opioid Prescribing after General Surgical Operations Ann Surg 2017;XX:1. doi:10.1097/SLA.0000000000002198.
- Baratta J L Clinical Consequences of Inadequate Pain Relief: Barriers to Optimal Pain Management Plastic and Reconstructive Surgery 2014; 134: Issue 4S-2-P15S-21S
- Johnston M et al Benefits of psychological preparation for surgery: a meta-analysis Annals of Behavioural Medicine 1993; 15: 245-246
- Macintyre PE & Schug SA Acute pain management: a practical guide (4 ed.) 2015
- Yang Michael MH et.al. Preoperative predictors of poor acute postoperative pain control: a systemic review and meta-analysis BMJ Open2019;9:e025091. doi:10.1136/bmjopen-2018-025091
- Cepeda M S Music for pain relief Cochrane Database Syst Rev (2) 2006: CD004843
- Romsing J et al Rectal and parenteral paracetamol, and paracetamol in combination with NSAIDsm for postoperative analgesia Br J Anaes 88;2:215-216
- Dunlevy Sue Suicides blamed on drug bungle: Opioid rules backfire Courier Mail, Page 3, 17 August 2020
- Lim Jessica SY, Kam Peter CA Neuroimmune mechanisms of pain: Basic science and potential therapeutic modulators Anaesthesia and Intensive Care 2020; 48: 167-178
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