Poorer clinical outcomes following postoperative opioid-related adverse events

By Nicole MacKee
One in 10 patients prescribed opioids after surgical or endoscopic procedures experience adverse drug events (ADEs) that are associated with poorer clinical outcomes, say US researchers.

In research published in JAMA Surgery, data were reviewed for 135,379 adults who underwent hospital-based surgical and endoscopic procedures and were given opioids. Overall, 10.6% of patients (14,386) experienced at least one opioid-related ADE, most of which were moderate or severe.

Older patients with multiple comorbidities were at higher risk of an ADE, the researchers reported. Patients with ADEs had received higher total opioid doses than those without (median morphine milligram equivalent dose, 46.8 vs 30.0 mg, respectively) and for a longer duration (median duration of three vs two days, respectively).

Adjusted analyses found that ADEs were associated with increased inpatient mortality, prolonged hospital stays, higher hospitalisation costs and a higher rate of 30-day readmission.

The researchers noted several study limitations, including a lack of information on the timing of the ADE relative to drug administration.

Associate Professor Malcolm Hogg, Head of Pain Management Services at Royal Melbourne Hospital, emphasised that this was an association study, and said it was to be expected that sicker patients would be prescribed higher opioid doses and be at greater risk of ADEs.

‘If you have a sick patient and you’re going to prescribe an opioid, it’s a flag to say this increases their risk, therefore, I should increase my monitoring and consider nonopioid treatment,’ Associate Professor Hogg told Medicine Today.

He said the research highlighted the importance of optimising pain management, particularly by using pain services and providing better linkages to community care.

He also pointed to the potential role of enhanced recovery after surgery (ERAS) pathways in reducing opioid use in surgical patients. ERAS pathways – in which patients received education, early feeding and mobilisation, nonopioid pain management and planned discharge – were currently used for patients undergoing orthopaedic and bowel surgery in Australia, but Professor Hogg said the model could be used more widely.

Improved monitoring of opioid ADEs and the introduction of governance measures, such as those used in antibiotic stewardship programs, should also be explored to reduce ADEs, he said.
JAMA Surg 2018; doi: 10.1001/jamasurg.2018.1039.