Opioids After Elective Ambulatory Thoracic Surgery – Canadian Association of Thoracic Surgeons

Guideline on the Prescription and Management of Opioids After Elective Ambulatory Thoracic Surgery

Background

Although the extent of contribution of post-surgical opioid prescription to the opioid crisis in Canada (and worldwide) remains a matter of debate, it is well established that opioids are significantly over prescribed. Some studies have shown that more than half of the individuals that misuse narcotics get them from friends or family. Indeed, left over pills are a major source of diversion, use and misuse. Only 5% – 60% of prescribed narcotics post-surgery are actually used. According to Health Canada, more than 9,000 people lost their lives in Canada between January 2016 and June 2018 related to opioids. Many individual institutions in different surgical disciplines have already adopted initiatives to minimize opioid over prescription. The committee therefore felt it is incumbent on CATS to contribute to the national debate and effort to address this tragic epidemic where it can best have an impact: the daily practice of post thoracic surgery narcotic prescription. Although thoracic surgery specific data is lacking, consensus statements and recommendations for procedures with postoperative pain commensurate with that of most common thoracic surgical procedures are available. The committee therefore relied on this data (referenced below) particularly consensus guidelines adopted by the U of T task force on post-surgery opioid use that included province wide input. Specialty specific guidelines utilized at large centres of excellence were also reviewed.

The ultimate goal is good daily function and not a “pain free” postoperative course.

Many studies have shown that patients who have minimally invasive procedures (VATS and laparoscopy) have less pain both early post-operatively and in the long term (1,2). It is therefore reasonable to manage post-operative pain based on surgical approach. For surgical approaches that may be more prone to increased acute and chronic post-operative pain (e.g. extra-pleural pneumonectomy, Pancoast tumour resection, clamshell incision), patients may require higher doses of analgesia. In such patients with more risk of developing post-operative pain, consideration should be given to adding adjuncts such as gabapentin to improve post-operative pain management and (3-6).

Given the gravity of the opioid crisis nationally, and despite the availability of level one evidence, the BP committee believes that sufficient experiential evidence, expert opinion, and guidelines adopted by centres of excellence for the committee to make recommendations.

Target Population

These recommendations apply to adult patients undergoing typical ambulatory elective thoracic surgery, including lung and foregut procedures but not including less common procedures or procedures only performed in specialized centers, such as lung transplantation, pulmonary thromboendarterectomy, en-bloc spinal resection, and extra-pleural pneumonectomy.

Intended Users

This recommendation is intended for use by health care providers involved in the management and care of thoracic surgical patients including surgeons, allied health professionals, anesthesiologists including the pain team, pharmacists and trainees.

Recommendations

1. Opioid-containing tablets to be prescribed at discharge

1.1. Following thoracic procedures of a minimal nature, often not requiring general anaesthesia, such as thoracentesis, chest tube or Tenchkoff catheter insertion, Patients should be prescribed 10 opioid-containing tablets.

1.2 Following VATS or minimally invasive surgery, patients discharged from hospital less than 7 days following surgery should be prescribed 15 opioid-containing tablets.

1.3 Following open thoracic surgery (thoracotomy/sternotomy/thoracoabdominal), patients discharged from hospital less than 7 days following surgery should be prescribed 30 opioid-containing tablets.

1.4. For patients who are discharged on POD >7, regardless of the type of operation, the number of opioid-containing tablets prescribed should be based on the number of opioid-containing tablets/medications that were prescribed in hospital in the 24 hours prior to discharge and other patient-specific information about their post-operative course.

1.4.1. Patients who took no tablets/received no opioids should not be prescribed any tablets.

1.4.2. Patients who took 1-3 tablets/24hrs should be prescribed 15 tablets at discharge.

1.4.3. Patients who took 4+ tablets/24 should be prescribed 30 tablets at discharge.

1.5. Patients should be prescribed the following opioid-containing tablets:

Hydromorphone 2mg, Q4H PRN.

1.6. In addition to or in the absence of opioid-containing tablets, patients should be discharged with the following adjunct pain medications:

1.6.1. Acetaminophen 1g PO q8hrs around the clock for 5 days and,

1.6.2. Ibuprofen 400 mg q8hrs around the clock for 3 days (with appropriate assessment of risk factors and patient education). Other NSAID may be substituted.

Suggested prescription sets:

(for opioid naïve patients)

Procedure

Minimally Invasive Surgery (MIS)

Open procedures*

LOS < 7days (Uncomplicated)

Prescription

Hydromorphone 2mg, Q4H PRN (15 tabs)

Acetaminophen 1g PO q8h (not PRN) 5days

Ibuprofen 400 mg q8h for 3 days**

NO REPEATS

Prescription

Hydromorphone 2mg, Q4H PRN (30 tabs)

Acetaminophen 1g PO q8hrs (not PRN) 5days

Ibuprofen 400 mg q8hrs for 3 days**

NO REPEATS

LOS >7 days

Use prescription as above BUT number of opioid-containing tablets prescribed should be based on the number of opioid-containing tablets/medications that were prescribed in hospital in the 24 hours prior to discharge and other patient-specific in-hospital course information.

· If no opioids being given at time of discharge then none should be prescribed

· If 1-3 tabs are being given per 24hrs then 15 tabs should be prescribed

· If 4+ tabs are being given per 24hrs then 30 tabs should be prescribed

* Does not include: Pancoast Tumour Resection, Extrapleural pneumonectomies

** Check for increased risk of UGI bleeding (e.g. pts on prednisone, anticoagulate, …)

Ongoing Narcotic Requirements

If the patient has ongoing narcotic requirements that are beyond the initial discharge prescription given, consideration should be given to referring the patient to a local chronic pain management group.

2. Risk factors for chronic opioid use perioperatively

2.1 Preoperatively, amongst the typical thoracic surgery population, the following patients may be at increased risk for postoperative opioid misuse:

Patients with a history of, or concurrent anxiety and/or depression
Patients with high levels of pain catastrophizing
Patients with a chronic pain diagnosis
Preoperative history of drug and/or alcohol use disorder
Patients using benzodiazepines and selective serotonin reuptake inhibitors

2.2 Patients seeking >1 refill prescription

2.3 For patients above that are linked with a higher risk of opioid abuse/overuse, involvement of a specialized pain service should be considered. Careful communication and involvement of family/referring physicians should be included if a second refill is requested.

3. Safe disposal of unused opioids

3.1 When prescribing medications, patients should be encouraged to store opioid medications safely out of the reach of children and preferably in a locked location.

3.2 Patients and their families should be provided with education about the proper disposal of unused opioid medications prior to discharge. Patients may return unused medications to pharmacies. Patients may also dispose of medications at home by:

3.2.1 Removing the medications from their original containers, scratching out all identifying information on the prescription label to help protect patient’s identity and the privacy of their personal health information.

3.2.2 Mixing the medications in something unappealing, such as used coffee grounds or kitty litter. This makes the drug less attractive to children and pets, and unrecognizable to people who go through the trash seeking drugs. Then place this mixture in a closed bag, empty can or other sealed container to prevent the drug from leaking or breaking out of a garbage bag.

4. Preoperative patient education

4.1 A University of Toronto patient education brochure agreed to by all Divisions covering expectations for post-operative pain, risk of addiction, and proper disposable is in development and will be circulated when completed.

Background

Target Population

Intended Users

Recommendations

Ongoing Narcotic Requirements

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