Are doctors still prescribing too many opioids?

A new study led by a McGill University scientist suggests opioid painkillers are not always beneficial — and sometimes harmful — as patients recover from minor surgery.

The research, published in The Lancet, examined the results of 47 randomized clinical trials in patients discharged after undergoing a minor or moderate procedure, ranging from molar extraction to foot surgery.

Dr. Julio Fiore, an assistant professor at McGill who researches post-operative recovery, said his team found that prescribed opioids had no more of an impact on the pain experienced after minor surgery than over-the-counter painkillers.

At the same time, the study found a significant increase in side effects, including nausea, vomiting and constipation.

Fiore said the findings suggest avoiding prescribing opioid painkillers could in many cases improve a patients' recovery experience, while helping to mitigate the well-documented perils of opioid addiction.

"We really expect that these findings encourage changes in prescribing practices," Fiore said in an interview.

"After all, like the prescription of opioids, like after discharge, our research showed that it does not seem to be as beneficial for patients as previously believed."

Fiore said there is a need for more research involving the prescription of opioids after major surgeries to determine best practices.

Of the studies examined, 30 involved minor procedures (most of which were dental) and 17 involved procedures of a more moderate nature on, for instance, a shoulder or foot.

Among the opioids most commonly prescribed by surgeons are oxycodone, hydromorphone, tramadol and codeine, according to the researchers.

Prescription opioids vary by country

The prescription of opioid painkillers varies widely across countries, and studies suggest Canadian doctors still prescribe more opioids than their counterparts in Europe — but not as much as doctors in the United States.

One 2019 study examining post-operative prescriptions found that almost half of U.S. patients had received high-dose opioid prescriptions after certain surgeries, which was nearly double the rate of Canada and nine times the rate of Sweden.

Dr. David Juurlink, head of clinical pharmacology at Sunnybrook Health Sciences Centre in Toronto, who was not involved with the study, said many doctors and dentists in Canada still put opioid painkillers on a "pedestal."

He said the study builds on previous research and his own experience as a practising doctor.

"The key message is these drugs are still valuable. They are certainly valuable in hospitals," Juurlink said, but then added that doctors and dentists should be "mindful of the fact that these drugs don't work as well as we were taught and they aren't as safe as we were taught. And very often, patients can do just fine without it."

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Last week, Ottawa and provincial governments reached a $150-million settlement with Purdue Pharma Canada for the recovery of health-care costs related to the sale and marketing of opioid-based pain medication.

Officials claimed Purdue Pharma, the maker of OxyContin, downplayed the risks of its drugs when advertising them to physicians, especially when it comes to their addictive potential, contributing to the opioid crisis.

Guidelines in place

Dr. Hance Clarke, an anesthesiologist and the medical director of the Pain Research Unit at Toronto General Hospital, also welcomed the findings. But he stressed that doctors are already better equipped than they were a decade ago to determine when to prescribe opioids.

In 2020, he helped develop guidelines for doctors that aimed to reduce the quantity of opioids prescribed so that fewer unused pills are available to those without a prescription.

Clarke said opioid painkillers can still serve an important role in patient recovery and pain management for some patients, especially after a major surgery.

He also cautioned against drawing a direct link between the prescription of opioid painkillers and the overdose crisis now unfolding in many Canadian communities, which experts say is now driven by the toxic supply of illicit drugs.

"I think we've come to understand that the opioid crisis is not a consequence of our perioperative opioid prescribing, but we could certainly do things better," said Clarke, who was not involved in the study.

"One of the things we can do is understand which types of surgeries might need the appropriate amount of opioids and which ones won't. And the paper is pretty clear that when you're dealing with pretty minor surgeries, opioids may be not necessary at all."