Heart surgery

Some heart surgery patients can control postoperative pain without opioids


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Many patients who have heart surgery may be able to safely and effectively control postoperative pain without opioids after hospital discharge, according to research published online today in The Annals of Thoracic Surgery.

In some cases, patients assume that after surgery, especially a major operation like heart surgery, they will need to go home with prescription pain relievers. This study shows that discharge without an opioid pain reliever after heart surgery is extremely well tolerated by some patients. In other words, we should not reflexively prescribe pain relievers to people after surgery just in case they need it. “

Catherine M. Wagner, MD, University of Michigan at Ann Arbor

Dr Wagner and colleagues looked at data from 2019 for patients who underwent coronary artery bypass grafting (CABG), heart valve surgery, or a combination of these via a median sternotomy (a vertical incision in the center of the chest) in 10 centers participating in the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative.

Researchers found that more than a quarter of patients (547/1924 or 28%) had not received a prescription for opioids when they were discharged. Older patients, who spent more time in the hospital after surgery, or who had surgery and were discharged in the last 3 months of the study period (October to December) were more likely that other patients will be discharged from the hospital without an opioid prescription. Conversely, patients with a history of depression, those who were treated with opioids the day before discharge, or patients whose race was neither black nor white were more likely to receive an opioid prescription after discharge. exit.

Importantly, the over-the-counter opioid discharge appears to have been well tolerated, as less than 2% of patients subsequently required a prescription after discharge and prior to their 30-day follow-up appointment.

“The results of this study should reassure patients that postoperative pain can be managed at home with non-opioid pain relievers,” said Dr. Wagner.

The researchers also found that of the 909 patients who had not taken opioids the day before discharge, 415 (46%) were still prescribed an opioid prescription upon discharge.

“The question is whether these opioid prescriptions were really necessary to relieve the pain of patients,” said Dr Wagner. “Our study shows that, especially for patients who did not take opioids the day before discharge from hospital, discharge without opioids is safe. I think we need to make sure that only patients who have badly needed opioids are sent home with a prescription. “

Opioid addiction continues to take its toll in the United States. Over 70% of overdose deaths in 2019 -; more than 49,000 deaths -; involved opioids, according to the U.S. Centers for Disease Control and Prevention (CDC). In 2021, more than 100,000 Americans died of overdoses (28.5% increase from the previous year); the CDC reports that the main driver of these deaths was opioids.

“For decades, surgeons have unwittingly but substantially contributed to the opioid epidemic,” said Thomas E. MacGillivray, MD, of Houston Methodist in Texas, who was not directly involved in this research. “No one wants a patient to go home after surgery without adequate pain relief. With the best intentions of helping with pain relief and pain-related anxiety relief, discharge practices have Often erred in prescribing too many narcotic pain pills rather than too few. We have learned that many of the unused and unnecessary narcotics end up in the community. This very important study will help surgeons identify patients who can easily re-enter at home without narcotics. “

Dr Wagner explained that before the relatively recent awareness of the opioid epidemic, patients were often prescribed 50 to 100 opioid tablets after surgery for a variety of reasons. Independent research has shown that leftover drugs can be diverted to the community, contributing to the opioid epidemic. With increased attention to overprescribing opioids for the treatment of pain after surgery, national efforts such as prescribing guidelines and patient education programs have begun to help “limit unnecessary opioids.” in the community and to reduce the risk of developing new persistent opioid use in patients ”. she said.

Going forward, the researchers plan to ensure that only patients who really need opioids are sent home with a prescription, while also eliminating “just in case” prescriptions that leave unnecessary opioids in their homes. communities and expose patients and their families to opioids. derivation.

“It is important to balance excellent pain control while limiting unnecessary opioids,” said Dr. Wagner. “We are always learning how to best find this balance for our patients and recommend that patients always work closely with their physician / provider teams to decide what is best for them. “

Source:

The Society of Thoracic Surgeons

Journal reference:

Wagner, CM, et al. (2021) Predictors of opioid-free home discharge after cardiac surgery: a multicenter analysis. The Annals of Thoracic Surgery. doi.org/10.1016/j.athoracsur.2021.10.005.

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