Guideline on the Prescription and Management of Opioids After Elective Ambulatory Thoracic Surgery
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.
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.
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.
- Ohbuchi T, Morikawa T, Takeuchi E, Kato H. Lobectomy: video-assisted thoracic surgery versus posterolateral thoracotomy. Jpn J Thorac Cardiovasc Surg.1998 Jun;46(6):519-22.
- Kwon ST, Zhao L, Reddy RM, Chang AC, Orringer MB, Crummett CM, Lin J. Evaluation of acute and chronic pain outcomes after robotic, video-assisted thoracoscopic surgery, or open anatomic pulmonary resection. J Thorac Cardiovasc Surg.2017 Aug;154(2):652-659.
- Hah J, Mackey SC, Schmidt P, McCue R, Humphreys K, Trafton J, Efron B et al. Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA Surg.2018 Apr 1;153(4):303-311.
- Ucak A, Onan B, Sen H, Selcuk I, Turan A, Yilmaz AT. The effects of gabapentin on acute and chronic postoperative pain after coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth.2011 Oct;25(5):824-9.
- Solak O, Metin M, Esme H, Solak O, Yaman M, Pekcolaklar A, Gurses A, Kavuncu V. Effectiveness of gabapentin in the treatment of chronic post-thoracotomy pain. Eur J Cardiothorac Surg.2007 Jul;32(1):9-12.
- Sihoe AD1, Lee TW, Wan IY, Thung KH, Yim AP.The use of gabapentin for post-operative and post-traumatic pain in thoracic surgery patients. Eur J Cardiothorac Surg.2006 May;29(5):795-9.
- Opioid Use After Discharge in Postoperative Patients A Systematic Review Adina E. Feinberg, MDCM, Tyler R. Chesney, MD, MSc, Sanjho Srikandarajah, MD, FRCPC,y Sergio A. Acuna, MD, PhD,z and Robin S. McLeod, MD, FRCSC, FACS,z on behalf of the Best Practice in Surgery Group