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Long-term Analgesic Use: Sometimes Less Is Not More

Long-term Analgesic Use: Sometimes Less Is Not More We read with interest the article by Alam et al.1 The investigators reported that the risk of long-term opioid use is greatly increased when prescribed in the first 7 days following a low-pain short-stay surgical procedure and suggest that “long-term postoperative analgesic use may best be addressed by preventing its initiation.”1(p428) We wonder if these conclusions can be wholly justified based on the figures presented and whether the problem of chronic postsurgical pain may be more significant than the authors suggest. It has been shown that the incidence of moderate to severe pain 24 hours after cataract surgery may be as high as 6.8%, and after laparoscopic cholecystectomy, 57.1%.2 This is certainly not low-pain surgery. The authors' figures show that most patients undergoing cataract surgery do not need further analgesia, but there is a group of patients who need pain relief in the subsequent week. It has been shown that pain at 24 hours may be much worse than immediately after the procedure.3 Rather than overprescribing analgesia in the first week, are we underestimating the pain of cataract surgery and putting patients at risk of chronic postsurgical pain at 1 year? The authors state that if chronic postsurgical pain were a significant factor, they would expect the risk of long-term analgesic use to be higher for laparoscopic cholecystectomy compared with the other groups studied, which was not the case. However, those undergoing laparoscopic cholecystectomy received more opioids in the immediate postoperative period than those undergoing cataract surgery (65.3% and 4.9%, respectively), so perhaps their acute pain was better anticipated and treated, decreasing their risk of progression to chronic pain. We support the broad concept of monitoring and reducing the long-term use of potentially harmful analgesics but believe this should be balanced by the understanding that inadequate treatment of pain in the elderly population can cause unnecessary suffering, delayed recovery, and adverse pathophysiological effects such as cardiac ischemia.4 Furthermore, persistent postsurgical pain may cause a loss of function and mobility and have deleterious psychosocial effects.5 While taking into account the potential adverse effects of long-term analgesic use, we stress that the emphasis should be on targeted multimodal pain therapies in the immediate postoperative period in order to decrease the requirement for long-term analgesic use. When it comes to perioperative analgesia, it is not a question of “less is more,” but “the correct amount is the right amount.” Back to top Article Information Correspondence: Dr Krishnamoorthy, Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104 (vkrish@u.washington.edu). Financial Disclosure: None reported. References 1. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425-43022412106PubMedGoogle ScholarCrossref 2. McGrath B, Elgendy H, Chung F, Kamming D, Curti B, King S. Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: a survey of 5,703 patients. Can J Anaesth. 2004;51(9):886-89115525613PubMedGoogle ScholarCrossref 3. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg. 1997;85(4):808-8169322460PubMedGoogle Scholar 4. Wu SS, Liu CL. Neural blockade: impact on outcome. In: Cousins MJ, Carr DB, Horlocker TT, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Pain Medicine. 4th ed. Philadelphia, PA: Wolters Kluwer and Lippincott Williams & Wilkins; 2008:144-159 5. Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain. 2004;112(1-2):1-415494176PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Long-term Analgesic Use: Sometimes Less Is Not More

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.2085
Publisher site
See Article on Publisher Site

Abstract

We read with interest the article by Alam et al.1 The investigators reported that the risk of long-term opioid use is greatly increased when prescribed in the first 7 days following a low-pain short-stay surgical procedure and suggest that “long-term postoperative analgesic use may best be addressed by preventing its initiation.”1(p428) We wonder if these conclusions can be wholly justified based on the figures presented and whether the problem of chronic postsurgical pain may be more significant than the authors suggest. It has been shown that the incidence of moderate to severe pain 24 hours after cataract surgery may be as high as 6.8%, and after laparoscopic cholecystectomy, 57.1%.2 This is certainly not low-pain surgery. The authors' figures show that most patients undergoing cataract surgery do not need further analgesia, but there is a group of patients who need pain relief in the subsequent week. It has been shown that pain at 24 hours may be much worse than immediately after the procedure.3 Rather than overprescribing analgesia in the first week, are we underestimating the pain of cataract surgery and putting patients at risk of chronic postsurgical pain at 1 year? The authors state that if chronic postsurgical pain were a significant factor, they would expect the risk of long-term analgesic use to be higher for laparoscopic cholecystectomy compared with the other groups studied, which was not the case. However, those undergoing laparoscopic cholecystectomy received more opioids in the immediate postoperative period than those undergoing cataract surgery (65.3% and 4.9%, respectively), so perhaps their acute pain was better anticipated and treated, decreasing their risk of progression to chronic pain. We support the broad concept of monitoring and reducing the long-term use of potentially harmful analgesics but believe this should be balanced by the understanding that inadequate treatment of pain in the elderly population can cause unnecessary suffering, delayed recovery, and adverse pathophysiological effects such as cardiac ischemia.4 Furthermore, persistent postsurgical pain may cause a loss of function and mobility and have deleterious psychosocial effects.5 While taking into account the potential adverse effects of long-term analgesic use, we stress that the emphasis should be on targeted multimodal pain therapies in the immediate postoperative period in order to decrease the requirement for long-term analgesic use. When it comes to perioperative analgesia, it is not a question of “less is more,” but “the correct amount is the right amount.” Back to top Article Information Correspondence: Dr Krishnamoorthy, Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104 (vkrish@u.washington.edu). Financial Disclosure: None reported. References 1. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425-43022412106PubMedGoogle ScholarCrossref 2. McGrath B, Elgendy H, Chung F, Kamming D, Curti B, King S. Thirty percent of patients have moderate to severe pain 24 hr after ambulatory surgery: a survey of 5,703 patients. Can J Anaesth. 2004;51(9):886-89115525613PubMedGoogle ScholarCrossref 3. Chung F, Ritchie E, Su J. Postoperative pain in ambulatory surgery. Anesth Analg. 1997;85(4):808-8169322460PubMedGoogle Scholar 4. Wu SS, Liu CL. Neural blockade: impact on outcome. In: Cousins MJ, Carr DB, Horlocker TT, Bridenbaugh PO, eds. Neural Blockade in Clinical Anesthesia and Pain Medicine. 4th ed. Philadelphia, PA: Wolters Kluwer and Lippincott Williams & Wilkins; 2008:144-159 5. Cousins MJ, Brennan F, Carr DB. Pain relief: a universal human right. Pain. 2004;112(1-2):1-415494176PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Aug 13, 2012

Keywords: analgesics

References