Background

Excessive opioid prescribing after surgery has contributed to the current opioid crisis; however, the value of prescribing opioids at surgical discharge remains uncertain. We aimed to estimate the extent to which opioid prescribing after discharge affects self-reported pain intensity and adverse events in comparison with an opioid-free analgesic regimen.

Methods

In this systematic review and meta-analysis, we searched MEDLINE, Embase, the Cochrane Library, Scopus, AMED, Biosis, and CINAHL from Jan 1, 1990, until July 8, 2021. We included multidose randomised controlled trials comparing opioid versus opioid-free analgesia in patients aged 15 years or older, discharged after undergoing a surgical procedure according to the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity definition (minor, moderate, major, and major complex). We screened articles, extracted data, and assessed risk of bias (Cochrane's risk-of-bias tool for randomised trials) in duplicate. The primary outcomes of interest were self-reported pain intensity on day 1 after discharge (standardised to 0–10 cm visual analogue scale) and vomiting up to 30 days. Pain intensity at further timepoints, pain interference, other adverse events, risk of dissatisfaction, and health-care reutilisation were also assessed. We did random-effects meta-analyses and appraised evidence certainty using the Grading of Recommendations, Assessment, Development, and Evaluations scoring system. The review was registered with PROSPERO (ID CRD42020153050).

Findings

47 trials (n=6607 patients) were included. 30 (64%) trials involved elective minor procedures (63% dental procedures) and 17 (36%) trials involved procedures of moderate extent (47% orthopaedic and 29% general surgery procedures). Compared with opioid-free analgesia, opioid prescribing did not reduce pain on the first day after discharge (weighted mean difference 0·01cm, 95% CI –0·26 to 0·27; moderate certainty) or at other postoperative timepoints (moderate-to-very-low certainty). Opioid prescribing was associated with increased risk of vomiting (relative risk 4·50, 95% CI 1·93 to 10·51; high certainty) and other adverse events, including nausea, constipation, dizziness, and drowsiness (high-to-moderate certainty). Opioids did not affect other outcomes.

Interpretation

Findings from this meta-analysis support that opioid prescribing at surgical discharge does not reduce pain intensity but does increase adverse events. Evidence relied on trials focused on elective surgeries of minor and moderate extent, suggesting that clinicians can consider prescribing opioid-free analgesia in these surgical settings. Data were largely derived from low-quality trials, and none involved patients having major or major-complex procedures. Given these limitations, there is a great need to advance the quality and scope of research in this field.

Funding

The Canadian Institutes of Health Research.

中文翻译：

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手术出院后阿片类药物与无阿片类药物镇痛：随机试验的系统评价和荟萃分析

背景

手术后过量的阿片类药物处方导致了当前的阿片类药物危机；然而，在手术出院时开阿片类药物的价值仍不确定。我们的目的是评估与无阿片类镇痛方案相比，出院后阿片类药物处方对自我报告的疼痛强度和不良事件的影响程度。

方法

在此系统评价和荟萃分析中，我们从 1990 年 1 月 1 日至 2021 年 7 月 8 日检索了 MEDLINE、Embase、Cochrane 图书馆、Scopus、AMED、Biosis 和 CINAHL。我们纳入了比较阿片类药物与阿片类药物的多剂量随机对照试验。根据死亡率和发病率定义（轻度、中度、重度和重度复合体）的生理和手术严重程度评分，在接受外科手术后出院的 15 岁或以上患者的免费镇痛。我们一式两份地筛选文章、提取数据并评估偏倚风险（Cochrane 的随机试验偏倚风险工具）。感兴趣的主要结果是出院后第 1 天自我报告的疼痛强度（标准化为 0-10 厘米视觉模拟量表）和长达 30 天的呕吐。进一步时间点的疼痛强度，还评估了疼痛干扰、其他不良事件、不满意的风险和医疗保健再利用。我们使用推荐分级、评估、开发和评估评分系统进行了随机效应荟萃分析并评估了证据的确定性。该评论已在 PROSPERO 注册（ID CRD42020153050）。

发现

纳入了 47 项试验（n=6607 名患者）。30 项 (64%) 试验涉及选择性小手术（63% 牙科手术），17 项 (36%) 试验涉及中等程度的手术（47% 骨科手术和 29% 普通外科手术）。与无阿片类药物镇痛相比，阿片类药物处方并没有减轻出院后第一天的疼痛（加权平均差 0·01cm，95% CI –0·26 至 0·27；中等确定性）或其他术后时间点（中等-到非常低的确定性）。阿片类药物处方与呕吐风险增加相关（相对风险 4·50，95% CI 1·93 至 10·51；高确定性）和其他不良事件，包括恶心、便秘、头晕和嗜睡（高至中度）肯定）。阿片类药物不影响其他结果。

解释

该荟萃分析的结果支持在手术出院时开阿片类药物不会降低疼痛强度，但会增加不良事件。证据依赖于侧重于轻度和中度择期手术的试验，表明临床医生可以考虑在这些手术环境中开具无阿片类药物的镇痛药。数据主要来自低质量的试验，没有一项涉及接受重大或重大复杂手术的患者。鉴于这些限制，非常需要提高该领域研究的质量和范围。

资金

加拿大卫生研究院。