In the Literature

Summary of "Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use"

Summary published August 28, 2023

Summary by Brian Thomas, JD

JAMA Surgery | June 2023

Santa Cruz Mercado LA, Liu R, Bharadwaj KM, Johnson JJ, Gutierrez R, Das P, Balanza G, Deng H, Pandit A, Stone TAD, Macdonald T, Horgan C, Tou SLJ, Houle TT, Bittner EA, Purdon PL. Association of Intraoperative Opioid Administration With Postoperative Pain and Opioid Use. JAMA Surg. 2023 Aug 1;158(8):854-864. doi: 10.1001/jamasurg.2023.2009. PMID: 37314800; PMCID: PMC10267849.

doi: https://doi.org/10.1001%2Fjamasurg.2023.2009

  • In this retrospective cohort study, the authors evaluated electronic health record data from a quaternary care academic medical center for adult patients who underwent noncardiac surgery with general anesthesia from April 2016 to March 2020.
  • The cohort study included a total of 61,249 individuals (mean [SD] age, 55.44 [17.08] years: 32,778 [53.5%] female).
  • The exposures studied were the mean intraoperative effect site concentrations for fentanyl and hydromorphone using previously validated pharmacokinetic/pharmacodynamic models.
  • The study objective was to understand the association between intraoperative opioid administration and postoperative pain and opioid usage over the short and long term.
  • The primary study outcomes were maximal pain score during the PACU stay and cumulative opioid dose administered in the PACU quantified in morphine milligram equivalents (MME).
  • Secondary outcomes included frequency of uncontrolled pain at 24 hours; new instances of chronic pain diagnosis between 3 months and 1 year; total opioid use at 24 hours and in the hospital; opioid prescriptions at 30, 90, and 180 postoperative days; frequency of new persistent opioid use at 90 and 180 days; maximal pain score in the first 24 hours and in the hospital; incidence of opioid-related complications in the PACU; length of stay in the PACU and in the hospital; 30 day readmission; and 30 day mortality.
  • The results of this study suggest that contrary to the current trend to reduce intraoperative opioid administration, this reduction may have the unintended consequence of increasing postoperative pain and opioid consumption. Conversely, adequate intraoperative nociception management, particularly with fentanyl, may result in improvements in postoperative pain management with a lower total quantity of opioid administration and a subsequent lower rate of new persistent opioid use.
  • The study’s authors conclude that these results raise important questions that require randomized clinical trials to verify causality between intraoperative opioid administration and long-term outcomes.