Helping surgical patients taper off opioids safely and successfully

A study following 251 surgical patients at risk of developing chronic pain or persistent opioid use at Toronto General Hospital (TG), University Health Network (UHN) found that almost half of patients who did not take opioids before surgery were able to wean off opioids, and one in four of those who did take opioids before surgery were able to wean completely.

Prescription opioids play an important role in addressing certain kinds of pain -- they are the best pharmacological option available for acute pain and widely used for cancer-related pain.

But the high overall rate of opioid prescribing in Canada has raised concerns, and prescribing in the context of non-cancer pain has been called into question. Health Quality Ontario and the Canadian Pain Society have created guidelines indicating opioids should not be considered the first line of defense in non-cancer pain.

Results are published in the Canadian Journal of Pain on August 20, 2018 under the title, "Opioid Weaning and Pain Management in Post-Surgical patients at the Toronto General Hospital Transitional Pain Service."

The study followed patients at high-risk for developing chronic pain and problematic opioid use for six months after surgery. In patients who did not take opioids for a year before surgery, the study found that 69 per cent were able to reduce their opioid consumption, with 45 per cent of them being able to stop completely.

Those patients who were taking a prescription opioid before surgery reduced their opioid use by 44 per cent, with 26 per cent of them weaning off completely.

"The assumption is that all patients after surgery are fine with their opioid use, but we have found that in a high-risk segment of patients, that is not the case," says Dr. Hance Clarke, Director of the Transitional Pain Service at TG. "We need better ways of identifying these patients, and then helping those who are having difficulty in reducing or eliminating their opioid use."

"Otherwise, we run the risk of de-escalating patients too fast and having them look elsewhere for opioids or other drugs if we don't guide them."

A 2016 study on the Transitional Pain Program at TG estimated that about 15 per cent of complex postoperative pain patients develop moderate to severe chronic, post-surgical pain, have significant disability and continue to use opioids for pain relief long-term.

Follow-up for the surgical patients referred to the Transitional Pain Program in this study included a phone call within 72 hours after surgery and follow-up meetings twice a month initially, and then monthly from three to six months. The goal is to prevent acute pain from becoming chronic post-surgical pain and taper opioid use or wean to zero if possible.

The Transitional Pain Program at TG uses a variety of methods to help and teach patients to manage their pain. These include prescribing non-opioid medications, use of psychological techniques, such as mindfulness or moment-by-moment awareness of our thoughts and sensations, as well as "exercise prescriptions" and acupuncture by a team of pain specialists, including physicians, nurses, psychologists, and physiotherapists.

The program also provides much-needed support for patients and primary care physicians after hospital discharge.

Sheldon Fine, 67, who is a medical oncologist in Peel Region, had thoracic surgery to remove a huge benign mass on his right lung in 2017. Because of the pain after his hospital discharge, he found himself on a daily dose of 120 milligrams of hydromorphone, a strong opioid that is five times more powerful than morphine.

With the help of the Transitional Pain Program at TG, his family and a strong desire to get off the opioid, he was able to taper down to 5 milligrams a day within five weeks, and eventually was able to get off the opioid completely.

Today, he runs marathons with his daughters and is back at work full-time.

"It was team work," he says. "The program involves patients every step of the way and sets milestones with them. They use different techniques such as physiotherapy and mindfulness training and the staff are so responsive to a patient's concerns and questions."

One of the strongest predictors in the study of remaining on opioids long-term after hospital discharge is the dose upon discharge: the higher the dose, the more likely the patient will remain on opioids long-term.

For patients who were on opioids before surgery, emotional distress factors such as anxiety or depression, and pain catastrophizing -- excessive pain-related worry, along with an inability to deflect thoughts from pain -- were important factors in how well these patients could wean off opioids.

A 2017 study on the Transitional Pain Program of post-surgical patients showed that a combined approach of mindfulness meditation along with specific psychological coping skills helped patients wean off high-doses of opioids and reduce their pain-related distress and disability.

"Identifying at-risk patients, typically those who have pre-existing pain, mental health issues, chronic use of opioids before surgery, is critical, so that we can develop follow-up plans, and educate patients and other healthcare clinicians," says Dr. Clarke, who is also the Medical Director of the Pain Research Unit at TG.

"We need to give patients the tools to manage their pain. Our clinical work and research suggests there is a powerful role for interventions other than opioids in helping patients manage their pain and suffering, taper their opioids and lead rich, meaningful lives.

"Our program is a good blueprint that we can use not only for surgical patients, but for anyone else dealing with an opioid addiction."

According to Public Health Ontario, here has been a steady increase in opioid-related harms in Ontario for more than a decade. Since 2003, the number of deaths has increased 136 per cent; more than 850 Ontarians died from opioid-related causes in 2016.

A 2017 report from the Institute for Clinical Evaluative Sciences (ICES), St. Michael's Hospital and the Ontario Drug Policy research Network (ODPRN) found that opioid-related deaths are occurring among all ages, incomes and in both sexes -- making it a widespread public health challenge.

A 2018 Health Quality Ontario Report found that surgeons in Ontario prescribed "new starts" of opioids to 265,643 patients in one year, and that eight per cent were above 90 mg of morphine equivalent (MEQ). (Family physicians prescribed "new starts" of opioids to 577,533 patients, with 1.7 per cent more than 90 MEQ, and dentists prescribed "new starts" to 219,853 patients, with 0.7 per cent more than 90 MEQ in the same time frame.)

The report notes that starting a patient on a dose of opioids higher than 90 MEQ has been shown to increase the risk of death from opioid poisoning relative to starting on a low dose.

"For a sub-population of patients who struggle with pain disability after surgery, it is important that we support them with appropriate pharmacological and non-pharmacological strategies," says Dr. Clarke, adding that the Transitional Pain Program at TG has developed non-opioid options in the treatment of chronic pain which should also be considered, consistent with Health Quality Ontario standards.