Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Abstract

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.

Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.

Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (β coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.

Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely.

Fig. 1

Patients contributed to the OPERAS study by country Full details are available in Table S1.

Fig. 2

Pain severity after discharge and satisfaction with pain treatment, stratified by procedure a Time in severe pain after discharge and b satisfaction with pain treatment. Violin and box plots show range, i.q.r., and median values. ACL, anterior cruciate ligament.

Fig. 3

Relationship between quantity of oral morphine equivalents prescribed at discharge and modelled time in severe pain and modelled patient satisfaction with pain treatment a Modelled time in severe pain and b modelled patient satisfaction with pain treatment adjusted for patient demographics, co-morbidity, operation type, duration and indication, preoperative opioid and non-opioid analgesia, postoperative complications, and oral morphine equivalent (OME) requirements 24 h before discharge. Each individual dot represents an individual patient. The solid lines and shaded areas represent the polynomial regression lines and 95% confidence intervals respectively.