Introduction
Background
Aims
Methods
Review design
Eligibility criteria
Study Criteria | Inclusion Criteria | Exclusion Criteria |
---|---|---|
Study design | Systematic review (± meta-analysis) | Non-reviews; protocols |
Population | Postsurgical patients exposed to acute / sub-acute pain (adults ± children) | Non-postsurgical patients; patients exposed to chronic pain; paediatric-only patients |
Intervention | Non-relevant intervention | |
Comparison | A method to analyse the efficacy of the intervention | No method to analyse the efficacy of the intervention |
Outcome | An outcome related to acute postoperative pain / opioid use / relevant clinical outcomes | An outcome unrelated to acute postoperative pain / opioid use / relevant clinical outcomes |
Search strategy
Study selection
Date extraction
Quality assessment
Data synthesis
Results
Search outcomes
Study characteristics
Authors | Year | Country | Included study design | No. of studies (total no. of participants) | Search period | Intervention | Primary outcome measures | Quality evaluation method |
---|---|---|---|---|---|---|---|---|
2019 | Switzerland | RCTs | 27 (1,630) | Up to 30 June 2019 | High-dose vs low-dose intraoperative opioids | Pain score at rest at 24 postoperative hours | GRADE | |
Arwi & Schug [23] | 2020 | Australia | NRSIs | 28 (661,441) | Up to 1 December 2018 | Opioids prescribed at discharge after inpatient care | The potential for harm of discharge opioids including excessive prescribing of discharge opioids, improper storage and disposal of opioids | Newcastle–Ottawa Quality Assessment Scale |
2022 | UK | RCTs and NRSIs | 31 (12,498) | Up to August 2020 | Unidimensional and functional assessment tools used for postoperative patients | Measurement error, cross-cultural validity, reliability, responsiveness, and hypothesis testing for construct validity | Modified version of the Newcastle–Ottawa Quality Assessment Scale; and COSMIN criteria for methodological quality | |
2017 | USA | RCTs and NRSIs | 6 (810) | Up to 20 July 2016 | Opioids prescribed for acute postoperative pain | The number of patients reporting any unused opioids | Newcastle–Ottawa Quality Assessment Scale | |
2018 | Canada | NRSIs | 11 (3,562) | Up to 17 December 2016 | Opioids prescribed for acute postoperative pain | The quantity of opioid medication used post-discharge | None | |
2020 | USA | RCTs and NRSIs | 43 (Not reported) | Not reported | Preoperative psychoeducational methods | The quality of preoperative psychoeducation and its effects on the outcome of surgery | Oxford levels of evidence | |
2021 | USA | RCTs and NRSIs | 16 (3,077) | Up to 2 October 2019 | Opioids prescribed for acute postoperative pain | Rates of disposal of unused opioids and the reported disposal mechanisms for unused opioids | SIGN checklists for cohort studies and RCTs | |
2020 | USA | NRSIs | 33 (1,922,743) | Up to 30 June 2019 | Postoperative opioid use | Risk factors associated with prolonged opioid use after surgery | Newcastle–Ottawa Quality Assessment Scale | |
2017 | France | RCTs | 135 (13,287) | Up to August 2015 | Non-opioid analgesics and tramadol prescribed for acute postoperative pain | Morphine consumption, pain, incidence of nausea, vomiting at 24 h and severe adverse effects | Cochrane Risk of Bias tool | |
2016 | UK | RCTs | 105 (10,302) | Up to May 2014 | Psychological preparation in adults undergoing elective surgery under general anaesthetic | Postoperative outcomes including pain, behavioural recovery, length of stay and negative affect | Cochrane Risk of Bias tool | |
2016 | Poland | Not reported | 53 (10,749) | January 1960 – 30 November 2015 | Preoperative psychological factors | Acute postoperative pain and analgesic consumption | Quality in Prognostic Studies tool | |
2018 | USA | RCTs and NRIs | 8 (2,272) | January 2000 – March 2018 | Behavioural intervention associated with postoperative prescribing | Postoperative opioid prescribing | Quality Assessment Tool for Quantitative Studies |
Authors | Main findings | Meta-analysis (yes/no) | Effect size with [95% confidence interval] | Degree of certainty | Priority |
---|---|---|---|---|---|
Albrecht et al | There is low certainty of evidence that high-dose intraoperative opioid administration increases pain scores in the post-operative period when compared with a low-dose regimen | Yes | Mean difference: -0.22 [-0.39, -0.05] | Low | Forget et al. 4 |
Arwi & Schug | The current discharge opioid prescribing practices can be improved. Lack of patient education regarding storage and disposal of opioids also contributes to the increasing rate of opioid misuse, diversion, and unintended long-term use. More high-quality research with comparable outcomes is needed. Evidence-based hospital guidelines and public health policies are needed to improve opioid stewardship | No | Not reported | Good – poor | Levy et al. 6 + 10 |
Baamer et al | This review found no evidence that any one unidimensional tool has superior measurement properties in assessing postoperative pain. In addition, because promoting function is a crucial perioperative goal, psychometric validation studies of functional pain assessment tools are needed to improve pain assessment and management | No | Not applicable | High – very low | Levy et al. 3 |
Bicket et al | Post-operative prescription opioids often go unused, unlocked, and undisposed, suggesting an important reservoir of opioids contributing to non-medical use of these products | No | Not reported | Intermediate | Levy et al. 10 |
Feinberg et al | Surgical patients are using substantially less opioids that prescribed. There is a lack of awareness regarding proper disposal of leftover medication, leaving excess opioids that may be used inappropriately by the patient or others. Education for providers and clinical practice guidelines that provide guidance on prescription of outpatient of opioids are required | No | Not reported | Not reported | Levy et al. 6 |
Horn et al | By addressing the psychological needs of patients through preoperative education, one can decrease postoperative recovery time and postsurgical acute pain. Reduced postsurgical acute pain results in fewer opioid prescriptions, which theoretically lowers the patient’s risk of developing chronic postsurgical pain, and potentially offers a novel concept using pre-emptive pain psychoeducation as a part of multimodal pain management solution to the opioid epidemic | No | Not reported | 1a – 3b | Levy et al. 2 |
Lamplot et al | Opioid pain medications are overprescribed postoperatively, and baseline rates of surplus opioid disposal are low. While it remains unclear whether patient education alone increases rates of safe opioid disposal, drug disposal kits or bags do appear to significantly increase these rates | No | Not reported | Acceptable | Levy et al. 10 |
Lawal et a | In this study, preoperative use of opioids and cocaine and the presence of comorbid pain conditions before surgery had the strongest associations with prolonged opioid use after surgery. These largely modifiable patient-level risk factors may be included as part of a comprehensive strategy to screen for at-risk individuals requiring transition to non-opioid interventions after surgery while ensuring appropriate short-term opioid use to manage postoperative pain. Research is needed to further investigate the association between surgical pain and prolonged opioid use after surgery | Yes | Not applicable | High | Levy et al. 1 |
Martinez et al | A combination of acetaminophen with either an NSAID or nefopam was superior to most non-morphine analgesic used alone, in reducing morphine consumption. Efficacy was best with three non-morphine analgesic used alone (α-2 agonists, NSAIDs and COX-2 inhibitors) and least with tramadol and acetaminophen. There is insufficient trial data reporting adverse events | No | Morphine consumption: -1 [-83 to 6.3] to -23.9 [-40.1 to -7.7] Pain: 0.8 [-14.9 to 16.5] to -12.4 [-21 to -3.8] | High – low and unclear risk of bias | Levy et al. 4 |
Powell et al | The evidence suggested that psychological preparation may be beneficial for the outcomes postoperative pain, behavioural recovery, negative affect and length of stay, and is unlikely to be harmful. However, at present, the strength of evidence is insufficient to reach firm conclusions on the role of psychological preparation for surgery. Further analyses are needed to explore the heterogeneity in the data, to identify more specifically when intervention techniques are of benefit. As the current evidence quality is low or very low, there is a need for well‐conducted and clearly reported research | Yes | Not reported | Low – very risk of bias | Levy et al. 2 |
Sobol-Kwapinska et al | Significant preoperative psychological correlates of acute postsurgical pain were the following: pain catastrophizing, expectation of pain, anxiety (state and trait), depression, optimism, negative affect and neuroticism/psychological vulnerability. Results of meta-analyses suggested that pain catastrophizing was most strongly associated with acute postsurgical pain. It must be noted that the expression ‘the most common/frequent correlates’ should not be confused with the ‘most important correlates’ | Yes | Correlation: r = 0.24 [0.11 to 0.36] to 0.41 [0.28 to 0.52] | Moderate – low risk of bias | Levy et al. 2 |
Wetzel et al | In this systematic review, interventions operating at a physician or organizational level (e.g., workflow changes) have shown positive results, while interventions at the patient level (e.g., patient education) have shown mixed results. Monitoring for negative consequences was key across the studies evaluated. The studies reviewed provide evidence that clinician-mediated and organizational-level interventions are powerful tools in creating change in postsurgical opioid prescribing. This summary highlights paucity of high-quality studies that provide clear evidence on the most effective intervention at reducing postoperative opioid prescribing | No | Not reported | Low | Forget et al. 1 |
Quality of the evidence
Research question and inclusion criteria include PICO components | A priori design | Justification of included study designs | Comprehensive literature search strategy | Study selection performed in duplicate | Data extraction in duplicate | List of excluded studies with justifications | Included studies describes in adequate detail | Satisfactory technique to assess risk of bias | Report on funding sources in studies | Appropriate method for statistical combination | Impact of RoB on meta-analysis results | Account for RoB in individual studies when interpreting results | Explanation of heterogeneity in results | Assessed publication bias | Reported conflicts of interest | Overall Quality | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Albrecht et al | Y | Y | Y | PY | Y | Y | N | P | Y | N | Y | Y | Y | Y | Y | Y | Low |
Arwi & Schug | Y | N | Y | N | Y | Y | N | Y | Y | N | N | N | Y | N | N | Y | Critically low |
Baamer et al | Y | N | Y | P | Y | Y | Y | Y | Y | N | N | N | Y | Y | N | Y | Low |
Bicket et al | Y | N | Y | P | Y | Y | N | Y | Y | Y | N | N | N | Y | N | Y | Critically low |
Feinberg et al | Y | N | Y | P | Y | N | N | Y | N | N | N | N | N | N | N | N | Critically low |
Horn et al | N | N | Y | Y | Y | N | N | N | N | N | N | N | N | N | N | N | Critically low |
Lamplot et al | Y | N | Y | Y | Y | Y | N | N | N | Y | Y | N | Y | ||||
Lawal et a | Y | Y | Y | P | Y | Y | N | Y | N | N | Y | Y | Y | Y | Y | Y | Critically low |
Martinez et al | Y | Y | Y | P | Y | Y | Y | Y | Y | Y | N | Y | N | Y | |||
Powell et al | Y | Y | Y | Y | Y | Y | Y | Y | Y | N | Y | Y | Y | Y | Y | Y | High |
Sobol-Kwapinska et al | Y | N | N | P | Y | Y | N | N | Y | N | Y | Y | Y | Y | Y | Y | Critically low |
Wetzel et al | Y | N | Y | P | N | Y | N | P | N | N | N | N | N | N | N | Y | Critically low |
Recommendation domain | SRs/meta-analysis quality | Degree of certainty |
---|---|---|
Risks with opioids | 1 SR with MA (critically low quality) | Low |
Preoperative optimisation | 2 SRs with MA + 1 SR without MA (high – critically low quality) | High – low |
Functional outcomes-based analgesia | 1 SR without MA (low quality) | Low |
Multimodal analgesia | 1 SR without MA (quality could not be assessed) | Uncertain |
Long-acting opioids | No SRs | Uncertain |
Patient-centred treatment duration | 2 SRs without MA (critically low quality) | Low |
Post-discharge repeat prescriptions | No SRs | Uncertain |
Opioid-induced ventilatory impairment | No SRs | Uncertain |
Modifiable factors | No SRs | Uncertain |
Safe opioid storage and disposal | 3 SRs without MA (critically low quality | Low |
Opioid Stewardship Steering Committee | 1 SR without MA (critically low quality) | Low |
Safe and accountable opioid use policies | No SRs | Uncertain |
Policies on opioid prescriptions determinants | No SRs | Uncertain |
Opioid treatment (dose and duration) policies | 1 SR with MA (low quality) | Low |
Follow-up and referral guidelines | No SRs | Uncertain |
Monitoring of opioid prescriptions | No SRs | Uncertain |
Preventing obstacles to access appropriate opioid prescription | No SRs | Uncertain |
Opioid disposal | No SRs | Uncertain |
Benchmarking | No SRs | Uncertain |
Improved interaction primary/secondary care | No SRs | Uncertain |