Post-Operative Pain Management in Lung Transplant Recipients: A Focus on Opioid Use

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Purpose Effective management of post-operative pain in lung transplant recipients (LTR) can be challenging. LTR are highly vulnerable to opioid related adverse effects such as sedation, respiratory depression and gastrointestinal side effects. While systemic opioids have traditionally been used as the mainstay of post-operative pain management, there is now heightened awareness of their harmful effects. Internationally, increasing opioid prescriptions has corresponded with an increase in opioid abuse, adverse events and hospital admissions. In addition, the Australian and New Zealand College of Anaesthetists recently released a position statement recommending against the use of slow-release opioids in the management of patients with acute pain. The patterns of opioid use following lung transplantation (LT) have not been well described in the literature. This study examined the prescribing patterns at our centre including the type of opioid and non-opioid analgesia used, the length of opioid use and rates of opioid associated adverse events following LT. Methods We undertook a single center retrospective analysis of 56 patients undergoing LT from 2016 to 2019. Post-operative pain relief regimens were examined including opioid and non-opioid modalities used in the ICU, at hospital discharge, at 6 weeks, 3 months and 6 months following LT. The incidence of opioid related adverse events was examined. Results There was a large variation in analgesic modalities used in the immediate post-operative period. Thoracic epidural analgesia was used in 37.5% and extra-pleural catheters were used in 3.6%. The use of opioid analgesia was 100% in the ICU, 66.1% at discharge from hospital, 46.4% at 6 weeks, 8.9% at 3 months and 1.8% at 6 months. Opioid related adverse effects occurred in 17.9%. LTR who were prescribed long acting opioids in the ICU had a higher incidence of opioid-related adverse events (RR 3.27, 95% CI 1.05 - 10.21). Conclusion The majority of LTR have ceased opioid medication use by 3 months. The high incidence of early opioid related adverse events highlights the need to reduce early systemic opioid use. The development of a standardized approach to pain management could be considered and increased use of regional modalities could be used. Long acting opioids were linked to greater harm and their use should be minimized.