From OT Europe

Better the devil you know: Overview of opioids in postoperative pain management

EFORT

This article is part of an ongoing series to raise awareness of a broad set of topics that impact orthopaedic practice to broaden the collaborative discussion around improving patient surgical outcomes, especially postoperative pain management, and with developing solutions that improve practices across Europe. The opinions expressed in this interview are meant as an informal conversation to facilitate dialogue.

Prof. Winfried Meissner is the head of the pain unit in the department of anesthesiology and intensive care at Jena University Hospital in Jena, Germany. A year following his contribution to our continuing series on pain management, we asked him to review our analysis of previous contributions and provide commentary on the common discussion of opioid treatments in postoperative pain management (POPM).

Morphine, fentanyl and oxycodone, among the most powerful and long-standing analgesics, are also the most frequently misused. Opioids are in a class of their own for the treatment of pain, and ever increasingly in headlines as a public health threat. This puts substantial pressure on pain practitioners who rely on these pain management tools to gain the best outcomes for their patients while also balancing the risks — medical and political — of including opioids as a foundation of POPM.

Proper POPM pain treatment program

That debate has been ongoing, and the pinnacle discovery of pain practitioners would be to find a potent analgesic that treats a variety of different pain conditions without the risk of developing tolerance and thereby dependency or addiction. On both sides of the debate, health care professionals have the same goal in mind of providing the best outcomes for their patients. Through our review and discussions with past contributors to our discussions on pain management, there are clearly different routes at arriving there.

Having spent the past few years discussing a wide range of topics involving POPM approaches and practices with leaders in their professions across Europe, the topic of opiates has continued to weave its way into the conversation, regardless of the overarching topic, from mobility to wound closure to postoperative clinical stays. We reviewed where these topics on opiates emerged and discussed them with Prof. Meissner to highlight key points and to discuss where we go from here.

When Meissner contributed to our series a year ago, he provided an overview of pain measurement, shifting from measuring intensity to mobility. During that conversation, the discussion of opioid treatment came up when discussing the risks of overtreatment as well as preoperative use of opioid treatment as a risk factor for chronic post-surgical pain. In this context, Meissner argued for a broader toolkit to assess pain as the “fifth vital sign” to provide patients with better overall POPM outcomes.

“These facts still ring true,” Meissner confirms. There are numbers of initiatives to find measures to replace pain intensity by functional measures, such as a large project underway with funding from the EU Innovative Medicine Initiative where Meissner is coordinator of one of the pain projects. The aim of these types of studies is to find better measures for both clinical routine on one side and pharmaceutical studies on the other side to uncover the best practices that can innovatively approach problems of postoperative pain.

Pop culture vs what is seen in the clinic

As previously mentioned, news headlines are rife with the ever-more-frequent images showing a user of illicit drugs dying on the gurney as the patient is rushed into the emergency room. The culprit? That prescription of oxycodone from the knee injury or the fentanyl patch the patient continued to hoard. The CDC cites that from 2016 to 2017, synthetic opioid-involved overdose death rates increased 45.2%. Similar grave statistics are less prominently published in the European context, but the situation is no less serious, even if at lesser scale. Meissner points to the study by Winfried Häuser and colleagues in 2017 that showed different levels of epidemic at the national scale, necessitating different guidelines by country, especially Australia, Canada and Germany. Wherein the U.S. opioid conversation covers less than 2% of the world’s population, it has recently taken over much of the dialogue.

In this context, it is important to note that from the “Pain Out” data that Meissner brings, there are a number of places where patients in fact need more and better access to opioids, so blanket policies to restrict access to opioids are not founded by the country-to-country datasets. Many countries have low supplies and need this important pain management tool.

The data call for a broader view of the situation and a more nuanced approach. Where there are, at times, legitimate reasons for concern, it is also important to understand the risks that knee-jerk reactions to these concerns might create. There are clear, necessary uses for opioids for the treatment of acute pain. As Prof. Bart Morlion said in the April 2019 issue of Orthopaedics Today Europe, “Following surgery, the changing nociceptive system might require an initial use of opioids that should then be tapered off with multimodal pain strategies that do not rely on one single pharmacological agent. While each patient is different, it is rare that a pain plan can avoid 100% the use of opioids as a strong analgesic in the very first hours and days following a surgery.”

Evident from our conversations with the key leaders in orthopaedic and traumatological practices across Europe is that the “pop culture” view of opiate pain management, which imagines a doctor dispensing unlimited refills of the prescription, does not match well with the reality of practitioners committed to opioid reduction while still leveraging their efficacy. As Morlion noted, the benefits are known, and the strategies are commonly in place, for opioid reduction in POPM.

In fact, the term reduction in the context of opioids, continues to resonate. Prof. Mike Reed added to that during a discussion with him on wound closure following orthopaedic surgery in the March 2019 issue of Orthopaedics Today Europe, “Patient education, protocols and coordination of multimodal postoperative pain management to reduce the use of opiates all play a role in quickly returning patients to full mobility.”

In this context, it is clear the use of opiates for POPM are one arrow in the quiver to deliver the best outcomes from a multimodal approach to pain management.

Do no harm with opiates

There are clear reasons to be thoughtful and vigilant when applying any treatment that should “do no harm.” This moniker for the medical profession applies also to orthopaedic surgeons who find themselves slicing wounds, sawing bones, drilling screws and intervening in numbers of ways that in some way “cause” harm or pain by alleviating further harm or pain. What is the balance in reference to opiate treatment options?

As Meissner mentioned when discussing pain measurement, presurgical use of opioid treatment is a risk factor for chronic postsurgical pain. To what extent, then, should opiate treatment be considered as a continuing option beyond the acute phases of treatment?

“It is more like a curve than a line,” Meissner said. There is, indeed, too little usage on some ends and too much on the others, and to find the right balance, Meissner suggests, is the common theme throughout the previous articles about POPM: a sort of multimodal strategy to address the risks. It should not all be about opioids, where regional analgesia, ketamine and other treatments can be added to the mix.

As evidence that there are more steps that can be taken and more that can be done, a team of researchers in a cohort study in which Meissner participated in Spain evaluated 2,922 patients to explore the influence of analgesic therapy on outcomes. In this 2017 study, the researchers suggested “chronic pain before surgery and/or chronic opioid consumption, were associated with worsened pain outcomes, suggesting that rigorous control of chronic pain before surgery, and combining opioids with adjuvants and other analgesics perioperatively, might improve outcomes.” There has been no indication that use of opioids will prevent the “chronification” of pain and using ketamine intra-operatively along with regional analgesia helps prevent that chronification. For the short term, opioids are necessary, but the longer the opioid treatment is performed and at the higher doses, the more opportunity there is for problems to arise.

Next steps

Going beyond continuous improvement of our best practices and understanding where doing no harm becomes doing better good, in June 2018, João Espregueira-Mendes, MD, spoke to us about recent innovations in pain management that zeroed in — rather than from an analgesic vantagepoint, but from the “do no harm” model — on new procedures that could reduce the need for the pharmacological toolkit by increasing practices that focus on surgical procedures that reduce the requirement for long-term recovery. He said, for example, in reference to tissue engineering and regenerative medicine (TERM): “From TERM, we may become able to address several conditions in orthopaedics and in sports medicine avoiding repair, substitution or other physically invasive surgical procedures that can be contributing for postoperative pain.”

These types of innovations take the discussion beyond the acknowledgment and treatment of postoperative pain by shifting POPM to postoperative pain prevention.

One approach that Meissner points out as interesting is based on the work of Suzan E. and colleagues in 2018. This approach admonishes that treatment with opioids should be limited to immediately following surgery for best effectiveness. On the pharmaceutical side, Meissner points out the encouraging results of Cebranopadol (GRT-6005, Grünenthal), and others combining nociceptin opioid peptide and opioid peptide receptor agonist, still in clinical trials and, not to be forgotten, are non-pharmaceutical measures to support pain management, including, for example, relaxation techniques, or other early studies into transcutaneous electrical nerve stimulation for acute pain. While opioids prove to continue to be a strong tool in the pain practitioner’s arsenal and will not seem to go away for some time, these can ever-increasingly be supplemented by a variety of pain relief support options. Rather than looking for one single solution, Meissner emphasizes the importance that has been learned to combine approaches, such as with multimodal analgesia, looking toward more options into the future.

Espregueira-Mendes asked us to imagine, in today’s reality of a saw and prosthetics, “a slight pin prick on an old knee as a method to insert new cartilage that generates into a biological product that is as good as new.” These realities are not yet here today, but not too far off to be seen.

Our discussion today with Meissner as our moderator has been just a digital taste of the ongoing discussions being undertaken every day on such a key topic, one we have been following for years. With these continued discussions between contributors such as Meissner, Morlion and Reed, and Espregueira-Mendes, their teams, students and others, the image is already advancing of a world adapting to not only better approaches to limit opioid use but ones that prevent extended opioid misuse or abuse not just by limiting or reducing treatment, but by preventing pain prior to the harm.

In June 2019 in Lisbon, the EFORT Congress will provide the opportunity to discuss these topics further face-to-face with key opinion leaders like our supporting contributors. Until then, and still following those discussions, we will continue to bring you the topics that most interest you.

To further discuss the opinions expressed in this article or to suggest a key topic, engage on Twitter, Facebook and LinkedIn #painmanagement #changepain #POPM.

EFORT

This article is part of an ongoing series to raise awareness of a broad set of topics that impact orthopaedic practice to broaden the collaborative discussion around improving patient surgical outcomes, especially postoperative pain management, and with developing solutions that improve practices across Europe. The opinions expressed in this interview are meant as an informal conversation to facilitate dialogue.

Prof. Winfried Meissner is the head of the pain unit in the department of anesthesiology and intensive care at Jena University Hospital in Jena, Germany. A year following his contribution to our continuing series on pain management, we asked him to review our analysis of previous contributions and provide commentary on the common discussion of opioid treatments in postoperative pain management (POPM).

Morphine, fentanyl and oxycodone, among the most powerful and long-standing analgesics, are also the most frequently misused. Opioids are in a class of their own for the treatment of pain, and ever increasingly in headlines as a public health threat. This puts substantial pressure on pain practitioners who rely on these pain management tools to gain the best outcomes for their patients while also balancing the risks — medical and political — of including opioids as a foundation of POPM.

Proper POPM pain treatment program

That debate has been ongoing, and the pinnacle discovery of pain practitioners would be to find a potent analgesic that treats a variety of different pain conditions without the risk of developing tolerance and thereby dependency or addiction. On both sides of the debate, health care professionals have the same goal in mind of providing the best outcomes for their patients. Through our review and discussions with past contributors to our discussions on pain management, there are clearly different routes at arriving there.

Having spent the past few years discussing a wide range of topics involving POPM approaches and practices with leaders in their professions across Europe, the topic of opiates has continued to weave its way into the conversation, regardless of the overarching topic, from mobility to wound closure to postoperative clinical stays. We reviewed where these topics on opiates emerged and discussed them with Prof. Meissner to highlight key points and to discuss where we go from here.

When Meissner contributed to our series a year ago, he provided an overview of pain measurement, shifting from measuring intensity to mobility. During that conversation, the discussion of opioid treatment came up when discussing the risks of overtreatment as well as preoperative use of opioid treatment as a risk factor for chronic post-surgical pain. In this context, Meissner argued for a broader toolkit to assess pain as the “fifth vital sign” to provide patients with better overall POPM outcomes.

PAGE BREAK

“These facts still ring true,” Meissner confirms. There are numbers of initiatives to find measures to replace pain intensity by functional measures, such as a large project underway with funding from the EU Innovative Medicine Initiative where Meissner is coordinator of one of the pain projects. The aim of these types of studies is to find better measures for both clinical routine on one side and pharmaceutical studies on the other side to uncover the best practices that can innovatively approach problems of postoperative pain.

Pop culture vs what is seen in the clinic

As previously mentioned, news headlines are rife with the ever-more-frequent images showing a user of illicit drugs dying on the gurney as the patient is rushed into the emergency room. The culprit? That prescription of oxycodone from the knee injury or the fentanyl patch the patient continued to hoard. The CDC cites that from 2016 to 2017, synthetic opioid-involved overdose death rates increased 45.2%. Similar grave statistics are less prominently published in the European context, but the situation is no less serious, even if at lesser scale. Meissner points to the study by Winfried Häuser and colleagues in 2017 that showed different levels of epidemic at the national scale, necessitating different guidelines by country, especially Australia, Canada and Germany. Wherein the U.S. opioid conversation covers less than 2% of the world’s population, it has recently taken over much of the dialogue.

In this context, it is important to note that from the “Pain Out” data that Meissner brings, there are a number of places where patients in fact need more and better access to opioids, so blanket policies to restrict access to opioids are not founded by the country-to-country datasets. Many countries have low supplies and need this important pain management tool.

The data call for a broader view of the situation and a more nuanced approach. Where there are, at times, legitimate reasons for concern, it is also important to understand the risks that knee-jerk reactions to these concerns might create. There are clear, necessary uses for opioids for the treatment of acute pain. As Prof. Bart Morlion said in the April 2019 issue of Orthopaedics Today Europe, “Following surgery, the changing nociceptive system might require an initial use of opioids that should then be tapered off with multimodal pain strategies that do not rely on one single pharmacological agent. While each patient is different, it is rare that a pain plan can avoid 100% the use of opioids as a strong analgesic in the very first hours and days following a surgery.”

PAGE BREAK

Evident from our conversations with the key leaders in orthopaedic and traumatological practices across Europe is that the “pop culture” view of opiate pain management, which imagines a doctor dispensing unlimited refills of the prescription, does not match well with the reality of practitioners committed to opioid reduction while still leveraging their efficacy. As Morlion noted, the benefits are known, and the strategies are commonly in place, for opioid reduction in POPM.

In fact, the term reduction in the context of opioids, continues to resonate. Prof. Mike Reed added to that during a discussion with him on wound closure following orthopaedic surgery in the March 2019 issue of Orthopaedics Today Europe, “Patient education, protocols and coordination of multimodal postoperative pain management to reduce the use of opiates all play a role in quickly returning patients to full mobility.”

In this context, it is clear the use of opiates for POPM are one arrow in the quiver to deliver the best outcomes from a multimodal approach to pain management.

Do no harm with opiates

There are clear reasons to be thoughtful and vigilant when applying any treatment that should “do no harm.” This moniker for the medical profession applies also to orthopaedic surgeons who find themselves slicing wounds, sawing bones, drilling screws and intervening in numbers of ways that in some way “cause” harm or pain by alleviating further harm or pain. What is the balance in reference to opiate treatment options?

As Meissner mentioned when discussing pain measurement, presurgical use of opioid treatment is a risk factor for chronic postsurgical pain. To what extent, then, should opiate treatment be considered as a continuing option beyond the acute phases of treatment?

“It is more like a curve than a line,” Meissner said. There is, indeed, too little usage on some ends and too much on the others, and to find the right balance, Meissner suggests, is the common theme throughout the previous articles about POPM: a sort of multimodal strategy to address the risks. It should not all be about opioids, where regional analgesia, ketamine and other treatments can be added to the mix.

As evidence that there are more steps that can be taken and more that can be done, a team of researchers in a cohort study in which Meissner participated in Spain evaluated 2,922 patients to explore the influence of analgesic therapy on outcomes. In this 2017 study, the researchers suggested “chronic pain before surgery and/or chronic opioid consumption, were associated with worsened pain outcomes, suggesting that rigorous control of chronic pain before surgery, and combining opioids with adjuvants and other analgesics perioperatively, might improve outcomes.” There has been no indication that use of opioids will prevent the “chronification” of pain and using ketamine intra-operatively along with regional analgesia helps prevent that chronification. For the short term, opioids are necessary, but the longer the opioid treatment is performed and at the higher doses, the more opportunity there is for problems to arise.

PAGE BREAK

Next steps

Going beyond continuous improvement of our best practices and understanding where doing no harm becomes doing better good, in June 2018, João Espregueira-Mendes, MD, spoke to us about recent innovations in pain management that zeroed in — rather than from an analgesic vantagepoint, but from the “do no harm” model — on new procedures that could reduce the need for the pharmacological toolkit by increasing practices that focus on surgical procedures that reduce the requirement for long-term recovery. He said, for example, in reference to tissue engineering and regenerative medicine (TERM): “From TERM, we may become able to address several conditions in orthopaedics and in sports medicine avoiding repair, substitution or other physically invasive surgical procedures that can be contributing for postoperative pain.”

These types of innovations take the discussion beyond the acknowledgment and treatment of postoperative pain by shifting POPM to postoperative pain prevention.

One approach that Meissner points out as interesting is based on the work of Suzan E. and colleagues in 2018. This approach admonishes that treatment with opioids should be limited to immediately following surgery for best effectiveness. On the pharmaceutical side, Meissner points out the encouraging results of Cebranopadol (GRT-6005, Grünenthal), and others combining nociceptin opioid peptide and opioid peptide receptor agonist, still in clinical trials and, not to be forgotten, are non-pharmaceutical measures to support pain management, including, for example, relaxation techniques, or other early studies into transcutaneous electrical nerve stimulation for acute pain. While opioids prove to continue to be a strong tool in the pain practitioner’s arsenal and will not seem to go away for some time, these can ever-increasingly be supplemented by a variety of pain relief support options. Rather than looking for one single solution, Meissner emphasizes the importance that has been learned to combine approaches, such as with multimodal analgesia, looking toward more options into the future.

Espregueira-Mendes asked us to imagine, in today’s reality of a saw and prosthetics, “a slight pin prick on an old knee as a method to insert new cartilage that generates into a biological product that is as good as new.” These realities are not yet here today, but not too far off to be seen.

Our discussion today with Meissner as our moderator has been just a digital taste of the ongoing discussions being undertaken every day on such a key topic, one we have been following for years. With these continued discussions between contributors such as Meissner, Morlion and Reed, and Espregueira-Mendes, their teams, students and others, the image is already advancing of a world adapting to not only better approaches to limit opioid use but ones that prevent extended opioid misuse or abuse not just by limiting or reducing treatment, but by preventing pain prior to the harm.

PAGE BREAK

In June 2019 in Lisbon, the EFORT Congress will provide the opportunity to discuss these topics further face-to-face with key opinion leaders like our supporting contributors. Until then, and still following those discussions, we will continue to bring you the topics that most interest you.

To further discuss the opinions expressed in this article or to suggest a key topic, engage on Twitter, Facebook and LinkedIn #painmanagement #changepain #POPM.