The impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: a multi-specialty, prospective cohort study in 25 countries

BackgroundBalancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. Concern about inadequate analgesia after discharge contributes to excessive opioid prescribing, but the benefits of opioid prescription following discharge remains unclear. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures. MethodsThis 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 during the first week following discharge, and patient-reported satisfaction with pain relief 7 days following discharge. Secondary outcomes included patient-reported quality of life, representations to healthcare for inadequately treated pain, and representations for side effects of pain medication. Data were collected by in-hospital chart review and patient telephone interview one week after discharge. Mixed-effects multivariate models, adjusted for patient comorbidity, operative characteristics, postoperative factors, country, and centre, with and without propensity score matching, were used to analyse outcomes. FindingsThe study recruited 4,273 patients from 144 centres in 25 countries. Overall, 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10% (IQR 1 to 30%) of the first week after discharge and rated satisfaction with analgesia as 9/10 (IQR 8 to 10). On negative binomial regression, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio=1.52, 95% CI 1.31 to 1.76, p<0.001) but not with analgesia satisfaction (beta coefficient=0.92, 95% CI -1.52 to 3.36, p=0.468) when compared to opioid-free analgesia. Opioid analgesia on discharge was associated with an increased risk of representation to healthcare providers for medication side effects (OR 2.38 95%CI 1.36 to 4.17, p=0.004). While opioid prescribing varied dramatically between high income and low and middle income countries, patient reported outcomes did not. InterpretationOpioid analgesia prescription on discharge is not associated with decreased pain severity or satisfaction with analgesia after surgical discharge, but is associated with higher risk of representation for medication side effects. For many operations, opioid-free analgesia at surgical discharge should be routinely adopted without concern for uncontrolled pain or reduced patient satisfaction. What this study addsO_ST_ABSEvidence before this studyC_ST_ABSWe conducted a literature search between November 2019 and February 2021 for studies on the relationship between opioid prescription and patient reported satisfaction or pain after discharge from surgery. We searched MEDLINE, Google Scholar and ClinicalTrials.gov using the search terms "opioid", "surgery", "discharge" without any language restrictions. Several single centre and retrospective surgical series examined opioid prescription practices after surgery demonstrating overprescription. Global studies examining variations in opioid prescribing between countries are less common but demonstrate significant global variation in prescription practices. One recent systematic review and meta-analysis examined randomised controlled trials comparing opioid and opioid-free analgesia in the post-surgical-discharge, and showed no difference between the two groups, but was limited to elective minor and moderate surgical procedures. Added value of this studyThis large study provides patient-reported data on pain and patient satisfaction after discharge from surgery. This adds to the previous knowledge by including both minor and major operations in an acute and elective context, and multiple specialties. After adjustment, opioid analgesia on discharge was not associated with decreased time in severe pain or increased patient satisfaction, but was associated with an increased risk of re-presentation for medication side effects. We also demonstrate marked geographical variation in opioid prescribing practices with higher amounts prescribed in high income countries compared to low and middle income countries, without a similar variation in patient reported pain or satisfaction. Implications of all the available evidenceOpioids are often prescribed at the time of discharge from hospital following surgery, but the benefit of post-discharge opioids has been called into question. We found that that opioids do not reduce severity of pain during the first week after discharge and do not increase patient satisfaction. These data suggest that opioid-free analgesia at surgical discharge is feasible without the risk of increased pain or decreased satisfaction, and that opioids should be prescribed more selectively. Variation in opioid prescribing between countries is not associated with variations in pain or satisfaction, and suggests that a more uniform approach to analgesia prescribing is warranted.