Opioid Prescribing for Acute Postoperative Pain: An Overview of Systematic Reviews

Opioid Prescribing for Acute Postoperative Pain: An Overview of Systematic Reviews | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Opioid Prescribing for Acute Postoperative Pain: An Overview of Systematic Reviews Cara Louise McCorquodale, Rachel Greening, Ross Tulloch, Patrice Forget This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2873258/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Aug, 2023 Read the published version in BMC Anesthesiology → Version 1 posted 8 You are reading this latest preprint version Abstract Background National guidelines for rational opioid prescribing for acute postoperative pain are needed to optimise postoperative pain control and function whilst minimising opioid-related harm. Objectives This overview of systematic reviews aims to summarise and critically assess the quality of systematic reviews related to the 20 previously published recommendations (ten relevant at patient and prescriber levels and ten at a system / Public Health level). It also aims to identify gaps in research that require further efforts to fill these in order to augment the evidence behind creating national guidelines for rational opioid prescribing for acute postoperative pain. Methods A systematic database search using PubMed/MEDLINE and Cochrane was conducted in November 2022. Furthermore, reference lists were reviewed. All identified systematic reviews were assessed for eligibility. Data from each study was extracted using a pre-standardised data extraction form. The methodological quality of the included reviews was assessed by two independent reviewers using the AMSTAR 2 checklist. Descriptive synthesis of the results was performed. Results A total of 12 papers were eligible for analysis. Only eight out of the total 20 prioritised recommendations had systematic reviews that provided evidence related to them. These systematic reviews were most commonly of critically low quality. Conclusion The consensus papers provide guidance and recommendations based on the consensus of expert opinion that is based on the best available evidence. However, there is a lack of evidence supporting many of these consensus statements. Efforts to further analyse interventions that aim to reduce the rates of opioid prescribing and their adverse effects should therefore continue. opioid acute pain postsurgical postoperative Figures Figure 1 Background Liberal prescribing of opioids for postoperative pain relief increases the risk of persistent postoperative opioid use and adverse outcomes, which has reached epidemic proportions in certain countries, especially in the USA (Jalal et al., 2018) . These adverse outcomes include dependence, addiction, opioid use disorders, opioid-induced ventilatory impairment and overdose-related deaths (Forget et al., 2022) . A study by Gomes et al. (2018) assessed the burden of opioid-related deaths in the USA and found that the percentage of all deaths attributable to opioids increased by an alarming 292% (from 0.4–1.5%) between 2001 and 2016. Prescribers may unwittingly be playing a major part in this epidemic. A cohort study in 2019 found that 76.2% of surgical patients in the USA filled an opioid prescription within the first 7 days after a surgical procedure compared to 11.1% of surgical patients in Sweden (Ladha et al., 2019) . An iatrogenic driving factor to the overprescribing of opioids was the unrestricted titration of opioids to numerical pain scores, such as the ‘Pain as the 5th Vital Sign’ campaign, which has now been discredited (Levy et al., 2018) . To reduce the risk of harm from opioid prescribing in adult surgical patients, a universal multidisciplinary consensus is required. This consensus would aim to provide guidance on the rational and safe prescribing of perioperative and postoperative opioids, facilitating optimal functional recovery and minimising opioid-related adverse outcomes. Current Guidelines In the United Kingdom (UK), the Faculty of Pain Medicine released recommendations composed by a multi-organisational and multidisciplinary collaboration, setting out guiding principles for preoperative, perioperative, postoperative and post discharge opioid management. The aim of these recommendations is to reduce postoperative opioid use and the adverse effects caused by them. In summary, the Best Practice document gives the following recommendations on aspects of postoperative opioid management: 1) pain relief should be optimised; 2) pain assessment should involve functional assessment; 3) immediate-release opioids are preferred; 4) give advice on medicine self-administration on discharge; 5) local protocols for the prescription of discharge medications after surgery should be developed; 6) hospital discharge letter must explicitly state the recommended opioid dose, amount supplied and planned duration of use; 7) identify patients for de-escalation of opioids; 8) guidance should be given about necessary medicine review post-discharge (FPM, 2021) . There have been two consensus statement papers published in the last two years with the objective to provide a framework for better prescribing practices for postoperative opioids. The first consensus paper, by Levy et al. (2020) , was an international multidisciplinary consensus statement, which aimed to provide guidance in order to “assist healthcare professionals and hospitals across the world to implement effective opioid stewardship practices that achieve a balance between the administration of sufficient opioid analgesia to facilitate recovery and restoration of function, while concurrently minimising the risk of opioid-related harms” (Levy et al., 2020) . Levy et al. provides ten priority recommendations based on best evidence and, in the absence of such, expert opinion. The second paper was by Forget et al. , which aimed to propose a consensus, not only on the prescribing of opioids, but also on policies for system-level interventions. Their ten recommendations were approved by a panel of experts in the field, along with healthcare representatives from different related medical disciplines and patient representatives from around the world. Therefore, the research reflects the view of a multi-stakeholder panel and represents a breadth of perspectives. Although both papers provide valuable recommendations for opioid prescribing practices, they are based on expert opinion, rather than being evidence-based. Expert opinion is often sought during the development of governance and regulatory policies when there is insufficient empirical evidence to implement a policy or change. Expert opinion is an integral part of the multifaceted knowledge required for optimal practice of clinical medicine (Tonelli, 1999) . On the other hand, evidence-based medicine is centred around the incorporation of knowledge gained through clinical trials, systematic reviews (SRs) and meta-analyses (Sackett et al., 1996) . Evidence-based medicine integrates clinical experience and patient values with the best available research information. This overview of SRs aims to identify any evidence-based research that could supplement the two expert opinion-based consensus papers in order to add to the robustness of these recommendations. Aims The primary aim of this overview of SRs is to summarise the evidence and critically assess the quality of SRs that are relevant to the ten priorities of each of the Levy et al. 7 and Forget et al. 2 consensus statement papers. By doing so, this overview will assess the quality of evidence supporting these two consensuses. The secondary aim is to identify gaps in research that require further efforts to fill these in order to augment the evidence behind the creation of a consensus statement for rational opioid prescribing for acute postoperative pain. Methods Review Design This overview of reviews was conducted in accordance with the Cochrane Handbook for the Systematic Review of Interventions (Pollock et al., 2022) and reported following the Reporting guideline for overviews of healthcare interventions: the Preferred Reporting Items for Overviews of Reviews (PRIOR) statement (Gates et al., 2022) . Due to the nature of this literature-based project, no ethics approval was required. However, each of the SRs included state the ethics considerations and approval that they required. Eligibility Criteria The inclusion and exclusion criteria are shown in Table 1. Search Strategy The search strategy involved looking at the SRs cited in reference lists of the consensus statements by Levy et al. (2020) and Forget et al. (2022) in addition to an electronic literature search, which was conducted during November 2022 using PubMed/MEDLINE. Various search strategies were used to identify SRs relating to the ten priorities of the Levy et al. (2020) consensus and the ten priorities of the Forget et al. (2022) consensus. The complete search strategies are reported in Appendix 1. A search limit of ‘systematic review’ and ‘meta-analysis’ was added. Papers were retrieved through additional sources, such as hand-searching the reference list of the Acute Pain Management document (Schug et al., 2020) and consulting an expert in the field for relevant papers. Study Selection All identified citations were collated and uploaded to RefWorks 2 and duplicates were removed. Two independent reviewers (CM, RT) screened the titles and abstracts of identified articles to assess relevancy. Irrelevant articles were removed at this stage. Subsequently, full texts of selected articles were accessed and further screened by the same two reviewers (CM, RT) by applying the inclusion and exclusion criteria to assess eligibility. Articles that did not meet the eligibility criteria were removed. Any queries or uncertainties were discussed and resolved through discussion and consensus between the two reviewers (CM, RT) and a supervisor (PF). Date Extraction A standardised data extraction form was predefined to portray the study characteristics of included articles. The following data was extracted from each article into this data extraction form by a single author (CM): author, title, year of publication, country, search period, number of primary studies included, total number of participants, effect size, intervention, outcome measures, study methods, quality evaluation method, degree of certainty, meta-analysis (yes/no) and main findings. Quality Assessment The methodological quality of the included SRs was assessed by two independent reviewers (CM, RG) using the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) checklist (Shea et al., 2017) . The AMSTAR 2 checklist consists of ten items, including seven critical items. AMSTAR 2 does not generate an overall ‘score’, but rather it categorises the quality of the assessed article as one of the following: high (≤1 non-critical item weakness); moderate (>1 non-critical item weakness); low (1 critical item weakness, with or without non-critical weaknesses); critically low (>1 critical item weakness, with or without non-critical weaknesses). Data Synthesis A quantitative meta-analytic synthesis of the included SRs was not performed due to great heterogeneity across the reviews arising from differences in sample characteristics, as well as differences between methods and outcome measures. Therefore, the data was grouped to the relevant ten priorities of the Levy consensus (Levy et al., 2020) and the ten priorities of the Forget consensus (Forget et al., 2022) and descriptive synthesis of the results was performed. Results Search Outcomes In total, 1,063 studies were identified. 276 duplicate records were removed, leaving 787 studies to be screened. After title and abstract analysis, a further 771 papers were excluded based on inclusion and exclusion criteria. The full texts of 16 studies were sought for retrieval. One study could not be fully retrieved, therefore 15 full texts were retrieved and assessed. 12 studies met the inclusion and exclusion criteria and were used in this overview (Figure 1) . The list of studies excluded after full-text analysis and reasons are shown in Appendix 2. Study Characteristics A summary of the detailed characteristics of the included SRs is presented in Table 2 and their findings are summarised in Table 3. All 12 included SRs were published between 2016 and 2022. The included authors are from the USA (n = 5), UK (n = 2), Australia (n =1), Canada (n = 1), France (n = 1), Poland (n = 1) and Switzerland (n = 1). Three reviews included only randomised controlled trials (RCTs) (Albrecht et al., 2019; Martinez et al., 2017; Powell et al., 2016) ; three other reviews included only non-randomised studies of intervention (NRSIs) (Arwi & Schug, 2020; Feinberg et al., 2018; Lawal et al. 2020) ; five reviews included both RCTs and NRSIs (Baamer et al., 2022; Bicket et al., 2017; Horn et al., 2020; Lamplot et al., 2021; Wetzel et al., 2018) ; and one review did not specify the type of studies it included (Sobol-Kwapinska et al., 2016) . The number of studies in the SRs ranged from 6 to 135 with a mean of 41.33, and the total number of participants in these studies ranged from 810 to 1,922,743 with a mean of 220,197.58. However, one study did not report the total number of participants (Horn et al., 2020) . Only four out of the 12 included SRs were meta-analysed (Albrecht et al., 2019; Lawal et al., 2020; Powell et al., 2016; Sobol-Kwapinska et al., 2016) . There was heterogeneity with regards to quality evaluation methods used in the included SRs. Three SRs used the Newcastle-Ottawa Quality Assessment Scale (Arwi & Schug, 2020; Bicket et al., 2017; Lawal et al., 2020) ; two SRs used the Cochrane Risk of Bias Tool (Martinez et al., 2017; Powell et al., 2016) ; one SR used a modified version of the Newcastle-Ottawa Quality Assessment scale and Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria (Baamer et al., 2022) ; one SR used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) (Albrecht et al., 2019) ; one SR used the Oxford levels of evidence (Horn et al., 2020) ; one SR used the Scottish Intercollegiate Guidelines Network (SIGN) checklists for cohort studies and RCTs (Lamplot et al., 2021) ; one SR used the Quality in Prognostic Studies tool (Sobol-Kwapinska et al., 2016) ; one SR used the Quality Assessment Tool for Quantitative Studies (Wetzel et al., 2018) ; and, finally, one SR did not use a quality evaluation method to assess the quality of its included studies (Feinberg et al., 2018). Quality of the Evidence The quality of the included SRs was assessed using AMSTAR 2 checklist, which is presented in Table 4. The supplementary of three papers could not be accessed (Lamplot et al., 2021; Martinez et al., 2017; Wetzel et al., 2018) . The authors of these SRs were contacted to request access to their supplementary material; however, we did not receive a response. The SRs by Lamplot et al. (2021) and Martinez et al. (2017) could, therefore, not be fully assessed using the AMSTAR 2 checklist. The SR by Wetzel et al. (2018) had enough information in its full text and therefore was fully assessed; however, we cannot say if their supplementary material contains information that may alter their AMSTAR 2 tool results. According to the criteria of AMSTAR 2, seven of the ten SRs that could be fully assessed were of critically low quality, two were of low quality and one was of high quality. Items 2, 7 10, 11, 12 and 15 were rated particularly low amongst the included SRs. Only one SR that was able to be fully assessed reported the funding sources of the included SRs (Bicket et al., 2017) . Discussion Main Findings The aim of this overview was to summarise the evidence and critically assess the quality of SRs that are relevant to the ten priorities of the Levy consensus (Levy et al., 2021) and the ten priorities of the Forget consensus (Forget et al., 2022) . This overview has identified a total of 12 SRs, which related to only six out of the ten priorities of the Levy consensus (Levy et al., 2021) and two of the ten priorities of the Forget consensus (Forget et al., 2022) . This means that a total of 12 priorities from both consensuses do not have evidence that could be identified through the methods of this overview that either supports or opposes them. Thus, we have identified a gap in research that requires further attention and efforts to fill to enhance stewardship of opioid prescribing for acute postoperative pain. The SRs that were identified were generally of low quality according to the AMSTAR 2 checklist (seven were critically low, two were low, one was high and two could not be fully appraised). Hence, further research is required to produce evidence of a higher quality to support the consensuses and pave the way for future safer opioid prescribing. The AMSTAR 2 tool was developed in 2017 as an upgraded version of the original AMSTAR tool. It is a well-used valid and reliable appraisal tool (Lorenz et al., 2019) . Implications of Findings Within Current Literature The prescribing of opioids for acute postoperative pain remains a highly controversial topic. The two consensus statements provide very promising progress for the development of national protocols for the safe prescribing and stewardship of postoperative opioids. With regards to these consensus statements, With regards to priority 1 of the Levy consensus (“all patients undergoing surgery should be assumed to be at risk of developing persistent postoperative opioid use and opioid-induced ventilatory impairment and may need interventions to mitigate those risks”), the SR by Lawal et al. (2020) provided evidence to support this statement. They concluded that strategies, such as proactively screening for at-risk individuals, should be priorities to reduce the substantial burden that persistent opioid use after surgery elicits on public health. Lawal et al. reported that preoperative use of opioids and cocaine and the presence of comorbid pain conditions before surgery were found to have the strongest associations with persistent opioid use after surgery. These modifiable risk factors could be included in a comprehensive approach to identify patients at higher risk of persistent opioid use and opioid-induced ventilatory impairment. However, it should be noted that this evidence was of critically low quality according to the AMSTAR 2 checklist. Priority 2 of the Levy consensus (“Consider optimising management of pre-operative pain and psychological risk-factors before surgery, including weaning of opioids where possible. Ensure realistic expectations of postoperative pain control, both in hospital and after discharge”) has three included SRs that provide evidence to support it. First of all, the SR by Horn et al. (2020) concluded that addressing the psychological needs of patients through preoperative education can decrease acute postoperative pain, and therefore decrease the need for opioid consumption. Additionally, the SR by Powell et al. (2016) found evidence that suggested preoperative psychological preparation may be beneficial for various outcomes, such as postoperative pain, behavioural recovery, negative affect and length of stay in hospital. However, the strength of evidence they found was insufficient, thus they recommended that further research is required to support this. Finally, the SR by Sobol-Kwapinska et al. (2016) analysed the relations between presurgical psychological factors and acute postoperative pain. They identified numerous psychological variables that could be considered for optimising preoperative psychological risk factors before surgery, as recommended by Levy et al. (2020) . The quality of evidence according to the AMSTAR 2 checklist was noted to be critically low for the SRs by Horn et al. (2020) and Sobol-Kwapinska et al. (2016) , but was high for the Powell et al. (2016) SR. Baamer et al. (2022) provided evidence for priority 3 of the Levy consensus (“provision of opioid analgesia should be guided by functional outcomes, rather than unidimensional pain scores alone”) by challenging the validity and reliability of unidimensional tools to quantify acute postoperative pain. They also discovered that studies on functional outcomes assessment tools were scarce, and therefore proposed more research is necessary to assess the validity and reliability of such tools. The quality of this SR was low, according to the AMSTAR 2 tool. Thus, future research of a higher quality could be beneficial to further support priority 3 of the Levy consensus. Priority 4 of the Levy consensus (“multimodal analgesia should be optimised and patients educated about the use of non-pharmacological and non-opioid analgesia to reduce the amount and duration of opioids required to restore function”) was supported through evidence from the SR by Martinez et al. (2017) . This paper concluded that a multimodal regimen of non-opioid analgesics was superior to solitary use of a single non-opioid analgesia in reducing acute postoperative pain and morphine consumption. The supplementary material of this SR was unavailable, resulting in full quality appraisal being unachievable. More research could be done to further assess multimodal analgesic regimens to increase the validity of this recommendation from Levy et al. (2020) . There are two SRs found through the methodology of this overview that provide evidence for the 6 th priority of the Levy consensus (“a patient-centred approach should be used to limit the number of tablets and the duration of usual discharge opioid prescriptions, typically to less than a week”). Arwi and Schug (2020) suggest that the current opioid prescribing practices could be improved. The studies they analysed showed that discharge opioids contribute to prolonged opioid use. However, more high-quality research with comparable outcomes is needed. Additionally, the SR by Feinberg et al. (2018) reported that surgical patients are using substantially less opioid than prescribed, leading to excess opioids that may be used inappropriately by patients or others. The authors agreed that strategies and clinical practice guidelines are needed to better educate prescribers and help standardise postoperative opioid prescriptions. It should be noted that both these SRs were of critically low quality according to the AMSTAR 2 tool. It would be beneficial for research of a higher quality be carried out to further support the Levy consensus. The 10 th priority of the Levy consensus (“patients should be advised on safe storage and disposal of unused opioids and directed to avoid opioid diversion to other individuals (e.g. sharing with friends and family)”) was also supported by the Arwi and Schug (2020) SR. This paper reported that a lack of patient education regarding safe storage and disposal of opioids contributes to the increasing rate of opioid misuse, diversion and unintended persistent opioid use. However, the authors recommend that more high-quality research is needed on this topic. The SR by Bicket et al. (2017) provides further evidence for the 10 th priority. This paper concluded that postoperative opioid prescriptions often go unused, unlocked and undisposed, leading to a reservoir of opioids that contribute to the non-medical use of these products. Although both these SRs are of critically low quality according to the AMSTAR 2 checklist, they still provide important evidence that supports the 10 th priority of the Levy consensus. The SR by Lamplot et al. (2021) provides further evidence for priority 10 of the Levy consensus. They found that opioids are overprescribed for acute postoperative pain, and baseline rates of surplus opioid disposal are low. Furthermore, their results showed that drug disposal kits or bags help to significantly increase these rates. Due to the supplementary material being unavailable, we could not fully assess the quality of this SR. However, it provides valuable evidence for future strategies to increase the safe disposal of unused opioids. With regards to the Forget consensus, the 1 st priority (“the presence of a Pain Management, Analgesia or Opioid Stewardship Steering Committee, with multidisciplinary representation from Key Stakeholders is a priority in the context of acute pain, especially in the hospital”) has one included SR that provides supporting evidence (Wetzel et al., 2018) . Their results showed evidence that clinician-mediated and organisation-level interventions are effective at reducing postoperative opioid prescribing. The quality of this SR was critically low. However, it provides useful evidence to aid the development of an evidence-based clinical practice guidelines. Finally, Albrecht et al. (2019) found that there is overall low certainty of evidence that high-dose intraoperative opioids in patients under general anaesthesia increases pain scores and contributes to hyperalgesia in the postoperative period when compared to low-dose regimen. However, they proposed that additional robust methodology trials could better define the impact of each opioid regime on hospital and health-system recourses. This agrees with priority 4 of the Forget consensus (“policies should be developed providing guidelines on maximum doses and duration of treatment for high-risk medications such as opioids and high-risk combinations”) by suggesting more trials should be undertaken in order to help develop such policies. The quality of the Albrecht et al. (2019) SR was low according to the AMSTAR 2 checklist. Implications of Findings for Future Research The number of drug-related deaths has vastly risen over the past few decades in the UK. According to the National Drug-Related Deaths Database (NDRDD) for Scotland, there were 1,209 deaths in 2018 that were drug related in Scotland. Opioids were implicated in 77% of these deaths (Public Health Scotland, 2022) . This is a significant increase from 2017, when there were 867 drug-related deaths in Scotland. In England and Wales, there were 3,756 drug-related deaths in 2018, a 16% increase from 2017 (Office for National Statistics, 2021) . The rise in drug-related deaths is thought to be due to the increased availability and misuse of prescription and illicit opioids due to irrational prescribing, amongst other factors. There are concerns that the UK is closely following the trends of the devastating opioid epidemic seen in the USA. A solution to the contributing factor of liberal opioid prescribing for acute postoperative pain could be the implementation of national guidance and protocols. The Levy and Forget consensuses provide a strong framework for such protocols (Levy et al., 2020; Forget et al., 2022) . They are predominantly expert opinion based. Historically, medicine was based on the consensus of experts and their opinions on best practices. Though expert opinion is a highly regarded and useful method of gathering information, it is more valid when used concomitant with evidence-based literature for the creation of healthcare policies and protocols (Tonelli, 1999) . Further research is required to provide evidence of a higher quality to support these consensus statements. Strengths & Limitations This overview included SRs of varying settings that covered a range of topics regarding rational opioid prescribing, enabling the concise evaluation and summarisation of literature related to the ten priorities of the Levy consensus (Levy et al. 2021) and the ten priorities of the Forget consensus (Forget et al., 2022) . It therefore offers valuable insight into the evidence behind the two consensuses that are predominantly based on expert opinion. Furthermore, this overview was conducted in accordance with the Cochrane Handbook for the Systematic Review of Interventions (Pollock et al., 2022) , which is well-known and well-used guidance, thus increasing reliability. There are several limitations of this overview. Firstly, there was one SR that could not be accessed for full-text analysis which may have offered valuable evidence (Zorrilla-Vaca et al., 2022) . Additionally, the supplementary material of three included SRs was not available, despite requesting access from the authors, resulting in full quality appraisals being incomplete (Lamplot et al., 2021; Martinez et al., 2017; Wetzel et al., 2018) . There was significant heterogeneity amongst the SRs regarding interventions, outcome measures, and quality evaluation method, with only four out of the 12 included SRs including meta-analysis. This meant that the SRs were not comparable. However, they provided valuable evidence for the aim of this overview. Finally, another limitation of this overview is that the included papers were from a wide range of countries. Though this may provide useful information that could shape future rational opioid prescribing protocols, it may not be applicable to UK guidance. Conclusion In conclusion, this overview of SRs provides valuable insight into the evidence behind the Levy et al. and Forget et al. consensus statements on rational opioid prescribing. However, there is a dearth of research that is required to implement valid and reliable nation opioid prescribing protocols. This overview found that there are not enough papers with high quality evidence to support the Levy et al. and Forget et al. consensus statements. The papers that were identified were mainly of low quality. Therefore, more research of a higher quality is required. The liberal prescribing of opioids for acute postoperative pain requires urgent attention. For now, it could be greatly beneficial to implement the recommendations given in the Levy et al. and Forget et al. consensus statements. The consensus papers provide guidance based on the consensus of expert opinion that is based on the best available evidence. However, efforts to further analyse interventions that aim to reduce the rates of opioid prescribing and their adverse effects should continue. Declarations Ethics approval: Due to the nature of this literature-based project, no ethics approval was required. However, each of the systematic reviews included state the ethics considerations and approval that they required. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. Competing interests: Forget P received speaker/advisory board fees from Grunethal and Oncomfort. Funding: The authors received no specific funding for this work. 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Opioid prescribing after surgery in the United States, Canada, and Sweden. JAMA Netw Open , 2(9) , e1910734. doi: 10.1001/jamanetworkopen.2019.10734 Lamplot, J. D., Premkumar, A., James, E. W., Lawton, C. D., Pearle, A. D. (2021). Postoperative disposal of unused opioids: a systematic review. HSS Journal, 17(2) , 235-243. doi: 10.1177/15563316211001366 Lawal, O. D., Gold, J., Murthy, A., Ruchi, R., Bavry, E., Hume, A. L., Lewkowitz, A. K., Brothers, T., Wen, X. (2020). Rate and risk factors associated with prolonged opioid use after surgery: a systematic review and meta-analysis. JAMA Network Open, 3(6) , e207367. doi:10.1001/jamanetworkopen.2020.7367 Levy, N., Quinlan, J., El-Boghdadly, K., Fawcett, W. J., Agarwal, V., Bastable, R. B., Cox, F. J., de Boer, H. D., Dowdy, S. C., Hattingh, K., Knaggs, R. D., Mariano, E. R., Pelosi, P., Scott, M. J., Lobo, D. N. and Macintyre, P. E. (2021). An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. Anaesthesia , 76 , 520-536. https://doi.org/10.1111/anae.15262 Levy, N., Sturgess, J., Mills. (2018). “Pain as the fifth vital sign” and dependence on the “numerical pain scale” is being abandoned in the US: why?. Br J Anaesth , 120(3) , 435-438, doi: https://doi.org/10.1016/j.bja.2017.11.098 Lorenz, R. C., Matthias, K., Pieper, D., Wegewitz, U., Morche, J., Nocon, M., Rissling, O., Schirm, J., Jacobs, A. (2019). A psychometric study found AMSTAR 2 to be a valid and moderately reliable appraisal tool. J Clin Epidemiol , 114 , 133-140. doi: 10.1016/j.jclinepi.2019.05.028 Martinez, V., Beloeil, H., Marret, E., Fletcher, D., Ravaud, P., Trinquart, L. (2017). Non-opioid analgesics in adults after major surgery: systematic review with network meta-analysis of randomized trials. Br J Anaesth, 118(1) , 22-31. https://doi.org/10.1093/bja/aew391 Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., McGuinness, L. A., Stewart, L. A., Thomas, J., Tricco, A. C., Welch, V. A., Whitling, P., Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ , 372 , 71. doi: 10.1136/bmj.n71 Pollock, M., Fernandes, R. M., Becker, L. A., Pieper, D., Hartling, L. (2022). Chapter V: Overviews of Reviews. In: Cochrane Handbook for Systematic Reviews of Interventions version 6.3 (updated February 2022). Cochrane . Available from www.training.cochrane.org/handbook [Accessed 14 November 2022] Powell, R., Scott, N. W., Manyande, A., Bruce, J., Vogele, C., Byrne-Davis, L. M .T., Unsworth, M., Osmer, C., Johnston, M. (2016). Psychological preparation and postoperative outcomes for adults undergoing surgery under general anaesthesia. Cochrane Database of Systematic Reviews, (5) . doi: 10.1002/14651858.CD008646.pub2 Public Health Scotland. (2022). National drug related death database (Scotland): analysis of deaths occurring in 2017 and 2018. Public Health Scotland . Available at: https://publichealthscotland.scot/publications/national-drug-related-death-database-scotland/the-national-drug-related-deaths-database-scotland-report-analysis-of-deaths-occurring-in-2017-and-2018/ [Accessed 9 December 2022] Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. BMJ , 312(7023) , 71-2. doi: 10.1136/bmj.312.7023.71 Schug, S. A., Palmer, G. M., Scott, D. A., Alcock, M., Halliwell, R., Mott, F. D. (2020). Acute pain management: scientific evidence (fifth edition). Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine . Available at: https://www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf [Accessed 9 November 2022] Shea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., Moher, D., Tugwell, P., Welch, V., Kristjansson, E., Henry, D. A. (2017). AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ , 358 , j4008. doi: 10.1136/bmj.j4008 Sobol-Kwapinska, M., Babel, P., Plotek, W., Stelcer, B. (2016). Psychological correlates of acute postsurgical pain: a systematic review and meta-analysis. Eur J Pain , 20 , 1573-1586. https://doi.org/10.1002/ejp.886 Tonelli, M. R. (1999). In defense of expert opinion. Academic Medicine , 74(11) , 1187-92. doi: 10.1097/00001888-199911000-00010 Wetzel, M., Hockenberry, J., Raval, M. V. (2018). Interventions for postsurgical opioid prescribing: a systematic review. JAMA Surg , 53(10) , 948–54. doi:10.1001/jamasurg.2018.2731 Zorrilla-Vaca, A., Mena, G. E., Ramirez, P. T., Lee, B. H., Sideris, A., Wu, C. L. (2022). Effectiveness of postoperative opioid educational initiatives: a systematic review and meta-analysis. Anesth Analg , 134(5) , 940-951 doi: 10.1213/ANE.0000000000005634 Tables Tables 1-4 are available in the Supplementary Files section. Additional Declarations Competing interest reported. Forget P received speaker/advisory board fees from Grunethal and Oncomfort. Supplementary Files Tables.docx Appendix1.docx Appendix2.docx Cite Share Download PDF Status: Published Journal Publication published 30 Aug, 2023 Read the published version in BMC Anesthesiology → Version 1 posted Editorial decision: Major revision 20 Jun, 2023 Reviews received at journal 06 Jun, 2023 Reviewers agreed at journal 02 Jun, 2023 Reviewers invited by journal 02 Jun, 2023 Editor assigned by journal 02 Jun, 2023 Editor invited by journal 16 May, 2023 Submission checks completed at journal 16 May, 2023 First submitted to journal 28 Apr, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2873258","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":200949841,"identity":"52caf425-80c4-4b82-8ba9-12321e75cb88","order_by":0,"name":"Cara Louise McCorquodale","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+ElEQVRIiWNgGAWjYPADNgYZBvYGNtK08DDwHGCDcYjVIpGAXwt/+9mHHxhz7OT5pQ9vk/hQZsfDL/n22MMfDHXy/PINWLVInEk3lmDclmw4sy+tTHLGuWQeydl56cY8DIcNZ7Zht8WAIY0BqOVAgsEZHjNp3jZmHoPbOWbSDAxAkWM4tPA/Y/6BpKWex/7mGTNJoMNwa5FIY0O25TCPgQSPmQQPAzNOLRI3nrFZJIL80sNWbDnj3HEeiTNAh/EYgPySgD3E+tOYb3zcBgwxHuaNNz6UVcvxt4McVgEMMeYD2K0BgQRYUCAHC1GASGWjYBSMglEw4gAAtexNnYOk7d8AAAAASUVORK5CYII=","orcid":"","institution":"University of Aberdeen School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Cara","middleName":"Louise","lastName":"McCorquodale","suffix":""},{"id":200949844,"identity":"7815ef27-5c39-407b-888f-7f686186c3a4","order_by":1,"name":"Rachel Greening","email":"","orcid":"","institution":"NHS Greater Glasgow and Clyde","correspondingAuthor":false,"prefix":"","firstName":"Rachel","middleName":"","lastName":"Greening","suffix":""},{"id":200949845,"identity":"c5f704ac-0170-44bc-9aa5-89ca923af3ce","order_by":2,"name":"Ross Tulloch","email":"","orcid":"","institution":"University of Aberdeen School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ross","middleName":"","lastName":"Tulloch","suffix":""},{"id":200949846,"identity":"987bf4ba-c487-4271-82e2-511a4df15cc3","order_by":3,"name":"Patrice Forget","email":"","orcid":"","institution":"University of Aberdeen School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Patrice","middleName":"","lastName":"Forget","suffix":""}],"badges":[],"createdAt":"2023-04-28 13:44:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2873258/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2873258/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12871-023-02243-5","type":"published","date":"2023-08-30T15:09:42+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":37196378,"identity":"a9da4659-5cf3-47a4-90d8-44f8723eb686","added_by":"auto","created_at":"2023-05-18 13:43:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37715,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003ePreferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (2020)\u003c/strong\u003e\u003c/em\u003e\u003cem\u003e. This diagram illustrates the selection process of studies included in this systematic review and is based on the 2020 PRISMA flow diagram (Page et al., 2021).\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2873258/v1/dd05620b3653cfb34a8719be.png"},{"id":42782675,"identity":"f879988e-6d95-494b-83fe-80479d950222","added_by":"auto","created_at":"2023-09-07 15:17:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":394026,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2873258/v1/95ab1bff-cc84-4bd6-aaf9-5880c4702b70.pdf"},{"id":37196379,"identity":"16925a01-fa3d-479c-8251-9e98767426dd","added_by":"auto","created_at":"2023-05-18 13:43:48","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":32780,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-2873258/v1/c53131851e3e340f4616dbd6.docx"},{"id":37196380,"identity":"864b155b-6ecd-4f0e-9eb4-754be6d786c9","added_by":"auto","created_at":"2023-05-18 13:43:48","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14420,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-2873258/v1/a38a13290d721c96e2616389.docx"},{"id":37197547,"identity":"533e338c-c917-4249-915c-85234392614a","added_by":"auto","created_at":"2023-05-18 13:51:48","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15132,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2.docx","url":"https://assets-eu.researchsquare.com/files/rs-2873258/v1/c0e6760e53e9165a316650dd.docx"}],"financialInterests":"Competing interest reported. Forget P received speaker/advisory board fees from Grunethal and Oncomfort.","formattedTitle":"Opioid Prescribing for Acute Postoperative Pain: An Overview of Systematic Reviews","fulltext":[{"header":"Background","content":"\u003cp\u003eLiberal prescribing of opioids for postoperative pain relief increases the risk of persistent postoperative opioid use and adverse outcomes, which has reached epidemic proportions in certain countries, especially in the USA \u003cem\u003e(Jalal et al., 2018)\u003c/em\u003e. These adverse outcomes include dependence, addiction, opioid use disorders, opioid-induced ventilatory impairment and overdose-related deaths \u003cem\u003e(Forget et al., 2022)\u003c/em\u003e. A study by Gomes \u003cem\u003eet al. (2018)\u003c/em\u003e assessed the burden of opioid-related deaths in the USA and found that the percentage of all deaths attributable to opioids increased by an alarming 292% (from 0.4–1.5%) between 2001 and 2016. Prescribers may unwittingly be playing a major part in this epidemic. A cohort study in 2019 found that 76.2% of surgical patients in the USA filled an opioid prescription within the first 7 days after a surgical procedure compared to 11.1% of surgical patients in Sweden \u003cem\u003e(Ladha et al., 2019)\u003c/em\u003e. An iatrogenic driving factor to the overprescribing of opioids was the unrestricted titration of opioids to numerical pain scores, such as the ‘Pain as the 5th Vital Sign’ campaign, which has now been discredited \u003cem\u003e(Levy et al., 2018)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eTo reduce the risk of harm from opioid prescribing in adult surgical patients, a universal multidisciplinary consensus is required. This consensus would aim to provide guidance on the rational and safe prescribing of perioperative and postoperative opioids, facilitating optimal functional recovery and minimising opioid-related adverse outcomes.\u003c/p\u003e \u003cp\u003eCurrent Guidelines\u003c/p\u003e \u003cp\u003eIn the United Kingdom (UK), the Faculty of Pain Medicine released recommendations composed by a multi-organisational and multidisciplinary collaboration, setting out guiding principles for preoperative, perioperative, postoperative and post discharge opioid management. The aim of these recommendations is to reduce postoperative opioid use and the adverse effects caused by them. In summary, the Best Practice document gives the following recommendations on aspects of postoperative opioid management: 1) pain relief should be optimised; 2) pain assessment should involve functional assessment; 3) immediate-release opioids are preferred; 4) give advice on medicine self-administration on discharge; 5) local protocols for the prescription of discharge medications after surgery should be developed; 6) hospital discharge letter must explicitly state the recommended opioid dose, amount supplied and planned duration of use; 7) identify patients for de-escalation of opioids; 8) guidance should be given about necessary medicine review post-discharge \u003cem\u003e(FPM, 2021)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eThere have been two consensus statement papers published in the last two years with the objective to provide a framework for better prescribing practices for postoperative opioids. The first consensus paper, by Levy \u003cem\u003eet al. (2020)\u003c/em\u003e, was an international multidisciplinary consensus statement, which aimed to provide guidance in order to “assist healthcare professionals and hospitals across the world to implement effective opioid stewardship practices that achieve a balance between the administration of sufficient opioid analgesia to facilitate recovery and restoration of function, while concurrently minimising the risk of opioid-related harms” \u003cem\u003e(Levy et al., 2020)\u003c/em\u003e. Levy \u003cem\u003eet al.\u003c/em\u003e provides ten priority recommendations based on best evidence and, in the absence of such, expert opinion.\u003c/p\u003e \u003cp\u003eThe second paper was by Forget \u003cem\u003eet al.\u003c/em\u003e, which aimed to propose a consensus, not only on the prescribing of opioids, but also on policies for system-level interventions. Their ten recommendations were approved by a panel of experts in the field, along with healthcare representatives from different related medical disciplines and patient representatives from around the world. Therefore, the research reflects the view of a multi-stakeholder panel and represents a breadth of perspectives.\u003c/p\u003e \u003cp\u003eAlthough both papers provide valuable recommendations for opioid prescribing practices, they are based on expert opinion, rather than being evidence-based. Expert opinion is often sought during the development of governance and regulatory policies when there is insufficient empirical evidence to implement a policy or change. Expert opinion is an integral part of the multifaceted knowledge required for optimal practice of clinical medicine \u003cem\u003e(Tonelli, 1999)\u003c/em\u003e. On the other hand, evidence-based medicine is centred around the incorporation of knowledge gained through clinical trials, systematic reviews (SRs) and meta-analyses \u003cem\u003e(Sackett et al., 1996)\u003c/em\u003e. Evidence-based medicine integrates clinical experience and patient values with the best available research information. This overview of SRs aims to identify any evidence-based research that could supplement the two expert opinion-based consensus papers in order to add to the robustness of these recommendations.\u003c/p\u003e \u003cp\u003eAims\u003c/p\u003e \u003cp\u003eThe primary aim of this overview of SRs is to summarise the evidence and critically assess the quality of SRs that are relevant to the ten priorities of each of the Levy \u003cem\u003eet al.\u003c/em\u003e\u003csup\u003e7\u003c/sup\u003e and Forget \u003cem\u003eet al.\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e consensus statement papers. By doing so, this overview will assess the quality of evidence supporting these two consensuses. The secondary aim is to identify gaps in research that require further efforts to fill these in order to augment the evidence behind the creation of a consensus statement for rational opioid prescribing for acute postoperative pain.\u003c/p\u003e "},{"header":"Methods","content":"\u003ch2\u003eReview Design\u003c/h2\u003e\n\u003cp\u003eThis overview of reviews was conducted in accordance with the Cochrane Handbook for the Systematic Review of Interventions \u003cem\u003e(Pollock et al., 2022)\u003c/em\u003e and reported following the Reporting guideline for overviews of healthcare interventions: the Preferred Reporting Items for Overviews of Reviews (PRIOR) statement \u003cem\u003e(Gates et al., 2022)\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDue to the nature of this literature-based project, no ethics approval was required. However, each of the SRs included state the ethics considerations and approval that they required.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eEligibility Criteria\u003c/h2\u003e\n\u003cp\u003eThe inclusion and exclusion criteria are shown in Table 1.\u003c/p\u003e\n\u003ch2\u003eSearch Strategy\u003c/h2\u003e\n\u003cp\u003eThe search strategy involved looking at the SRs cited in reference lists of the consensus statements by Levy \u003cem\u003eet al. (2020)\u0026nbsp;\u003c/em\u003eand Forget \u003cem\u003eet al. (2022)\u003c/em\u003e in addition to an electronic literature search, which was conducted during November 2022 using PubMed/MEDLINE. Various search strategies were used to identify SRs relating to the ten priorities of the Levy \u003cem\u003eet al. (2020)\u0026nbsp;\u003c/em\u003econsensus and the ten priorities of the Forget \u003cem\u003eet al. (2022)\u0026nbsp;\u003c/em\u003econsensus. The complete search strategies are reported in Appendix 1. A search limit of \u0026lsquo;systematic review\u0026rsquo; and \u0026lsquo;meta-analysis\u0026rsquo; was added. Papers were retrieved through additional sources, such as hand-searching the reference list of the Acute Pain Management document \u003cem\u003e(Schug et al., 2020)\u0026nbsp;\u003c/em\u003eand consulting an expert in the field for relevant papers.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eStudy Selection\u003c/h2\u003e\n\u003cp\u003eAll identified citations were collated and uploaded to RefWorks 2 and duplicates were removed. Two independent reviewers (CM, RT) screened the titles and abstracts of identified articles to assess relevancy. Irrelevant articles were removed at this stage. Subsequently, full texts of selected articles were accessed and further screened by the same two reviewers (CM, RT) by applying the inclusion and exclusion criteria to assess eligibility. Articles that did not meet the eligibility criteria were removed. Any queries or uncertainties were discussed and resolved through discussion and consensus between the two reviewers (CM, RT) and a supervisor (PF).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eDate Extraction\u003c/h2\u003e\n\u003cp\u003eA standardised data extraction form was predefined to portray the study characteristics of included articles. The following data was extracted from each article into this data extraction form by a single author (CM): author, title, year of publication, country, search period, number of primary studies included, total number of participants, effect size, intervention, outcome measures, study methods, quality evaluation method, degree of certainty, meta-analysis (yes/no) and main findings.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eQuality Assessment\u003c/h2\u003e\n\u003cp\u003eThe methodological quality of the included SRs was assessed by two independent reviewers (CM, RG) using the Assessment of Multiple Systematic Reviews 2 (AMSTAR 2) checklist \u003cem\u003e(Shea et al., 2017)\u003c/em\u003e. The AMSTAR 2 checklist consists of ten items, including seven critical items. AMSTAR 2 does not generate an overall \u0026lsquo;score\u0026rsquo;, but rather it categorises the quality of the assessed article as one of the following: high (\u0026le;1 non-critical item weakness); moderate (\u0026gt;1 non-critical item weakness); low (1 critical item weakness, with or without non-critical weaknesses); critically low (\u0026gt;1 critical item weakness, with or without non-critical weaknesses).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData Synthesis\u003c/h2\u003e\n\u003cp\u003eA quantitative meta-analytic synthesis of the included SRs was not performed due to great heterogeneity across the reviews arising from differences in sample characteristics, as well as differences between methods and outcome measures. Therefore, the data was grouped to the relevant ten priorities of the Levy consensus \u003cem\u003e(Levy et al., 2020)\u0026nbsp;\u003c/em\u003eand the ten priorities of the Forget consensus \u003cem\u003e(Forget et al., 2022)\u003c/em\u003e and descriptive synthesis of the results was performed.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eSearch Outcomes\u003c/h2\u003e\n\u003cp\u003eIn total, 1,063 studies were identified. 276 duplicate records were removed, leaving 787 studies to be screened. After title and abstract analysis, a further 771 papers were excluded based on inclusion and exclusion criteria. The full texts of 16 studies were sought for retrieval. One study could not be fully retrieved, therefore 15 full texts were retrieved and assessed. 12 studies met the inclusion and exclusion criteria and were used in this overview \u003cem\u003e(Figure 1)\u003c/em\u003e. The list of studies excluded after full-text analysis and reasons are shown in Appendix 2.\u003c/p\u003e\n\u003ch2\u003eStudy Characteristics\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eA summary of the detailed characteristics of the included SRs is presented in Table 2 and their findings are summarised in Table 3. All 12 included SRs were published between 2016 and 2022. The included authors are from the USA (n = 5), UK (n = 2), Australia (n =1), Canada (n = 1), France (n = 1), Poland (n = 1) and Switzerland (n = 1). Three reviews included only randomised controlled trials (RCTs) \u003cem\u003e(Albrecht et al., 2019; Martinez et al., 2017; Powell et al., 2016)\u003c/em\u003e; three other reviews included only non-randomised studies of intervention (NRSIs) \u003cem\u003e(Arwi \u0026amp; Schug, 2020; Feinberg et al., 2018; Lawal et al. 2020)\u003c/em\u003e; five reviews included both RCTs and NRSIs \u003cem\u003e(Baamer et al., 2022; Bicket et al., 2017; Horn et al., 2020; Lamplot et al., 2021; Wetzel et al., 2018)\u003c/em\u003e; and one review did not specify the type of studies it included \u003cem\u003e(Sobol-Kwapinska et al., 2016)\u003c/em\u003e. The number of studies in the SRs ranged from 6 to 135 with a mean of 41.33, and the total number of participants in these studies ranged from 810 to 1,922,743 with a mean of 220,197.58. However, one study did not report the total number of participants \u003cem\u003e(Horn et al., 2020)\u003c/em\u003e. Only four out of the 12 included SRs were meta-analysed \u003cem\u003e(Albrecht et al., 2019; Lawal et al., 2020; Powell et al., 2016; Sobol-Kwapinska et al., 2016)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eThere was heterogeneity with regards to quality evaluation methods used in the included SRs. \u0026nbsp;Three SRs used the Newcastle-Ottawa Quality Assessment Scale \u003cem\u003e(Arwi \u0026amp; Schug, 2020; Bicket et al., 2017; Lawal et al., 2020)\u003c/em\u003e; two SRs used the Cochrane Risk of Bias Tool \u003cem\u003e(Martinez et al., 2017; Powell et al., 2016)\u003c/em\u003e; one SR used a modified version of the Newcastle-Ottawa Quality Assessment scale and Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) criteria \u003cem\u003e(Baamer et al., 2022)\u003c/em\u003e; one SR used Grading of Recommendations, Assessment, Development and Evaluations (GRADE) \u003cem\u003e(Albrecht et al., 2019)\u003c/em\u003e; one SR used the Oxford levels of evidence \u003cem\u003e(Horn et al., 2020)\u003c/em\u003e; one SR used the Scottish Intercollegiate Guidelines Network (SIGN) checklists for cohort studies and RCTs \u003cem\u003e(Lamplot et al., 2021)\u003c/em\u003e; one SR used the Quality in Prognostic Studies tool \u003cem\u003e(Sobol-Kwapinska et al., 2016)\u003c/em\u003e; one SR used the Quality Assessment Tool for Quantitative Studies \u003cem\u003e(Wetzel et al., 2018)\u003c/em\u003e; and, finally, one SR did not use a quality evaluation method to assess the quality of its included studies \u003cem\u003e(Feinberg et al., 2018).\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eQuality of the Evidence\u003c/h2\u003e\n\u003cp\u003eThe quality of the included SRs was assessed using AMSTAR 2 checklist, which is presented in Table 4. The supplementary of three papers could not be accessed \u003cem\u003e(Lamplot et al., 2021; Martinez et al., 2017; Wetzel et al., 2018)\u003c/em\u003e. The authors of these SRs were contacted to request access to their supplementary material; however, we did not receive a response. The SRs by Lamplot \u003cem\u003eet al. (2021)\u003c/em\u003e and Martinez \u003cem\u003eet al. (2017)\u003c/em\u003e could, therefore, not be fully assessed using the AMSTAR 2 checklist. The SR by Wetzel \u003cem\u003eet al.\u003c/em\u003e \u003cem\u003e(2018)\u003c/em\u003e had enough information in its full text and therefore was fully assessed; however, we cannot say if their supplementary material contains information that may alter their AMSTAR 2 tool results.\u003c/p\u003e\n\u003cp\u003eAccording to the criteria of AMSTAR 2, seven of the ten SRs that could be fully assessed were of critically low quality, two were of low quality and one was of high quality. Items 2, 7 10, 11, 12 and 15 were rated particularly low amongst the included SRs. Only one SR that was able to be fully assessed reported the funding sources of the included SRs \u003cem\u003e(Bicket et al., 2017)\u003c/em\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch2\u003eMain Findings\u003c/h2\u003e\n\u003cp\u003eThe aim of this overview was\u0026nbsp;to summarise the evidence and critically assess the quality of SRs that are relevant to the ten priorities of the Levy consensus \u003cem\u003e(Levy et al., 2021)\u003c/em\u003e and the ten priorities of the Forget consensus \u003cem\u003e(Forget et al., 2022)\u003c/em\u003e. \u0026nbsp;This overview has identified a total of 12 SRs, which related to only six out of the ten priorities of the Levy consensus\u003cem\u003e\u0026nbsp;(Levy et al., 2021)\u003c/em\u003e and two of the ten priorities of the Forget consensus \u003cem\u003e(Forget et al., 2022)\u003c/em\u003e. This means that a total of 12 priorities from both consensuses do not have evidence that could be identified through the methods of this overview that either supports or opposes them. Thus, we have identified a gap in research that requires further attention and efforts to fill to enhance stewardship of opioid prescribing for acute postoperative pain.\u003c/p\u003e\n\u003cp\u003eThe SRs that were identified were generally of low quality according to the AMSTAR 2 checklist (seven were critically low, two were low, one was high and two could not be fully appraised). Hence, further research is required to produce evidence of a higher quality to support the consensuses and pave the way for future safer opioid prescribing. The AMSTAR 2 tool was developed in 2017 as an upgraded version of the original AMSTAR tool. It is a well-used valid and reliable appraisal tool \u003cem\u003e(Lorenz et al., 2019)\u003c/em\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eImplications of Findings Within Current Literature\u003c/h2\u003e\n\u003cp\u003eThe prescribing of opioids for acute postoperative pain remains a highly controversial topic. The two consensus statements provide very promising progress for the development of national protocols for the safe prescribing and stewardship of postoperative opioids. With regards to these consensus statements,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWith regards to priority 1 of the Levy consensus (\u0026ldquo;all patients undergoing surgery should be assumed to be at risk of developing persistent postoperative opioid use and opioid-induced ventilatory impairment and may need interventions to mitigate those risks\u0026rdquo;), the SR by Lawal \u003cem\u003eet al. (2020)\u003c/em\u003e provided evidence to support this statement. They concluded that strategies, such as proactively screening for at-risk individuals, should be priorities to reduce the substantial burden that persistent opioid use after surgery elicits on public health. Lawal \u003cem\u003eet al.\u003c/em\u003e reported that preoperative use of opioids and cocaine and the presence of comorbid pain conditions before surgery were found to have the strongest associations with persistent opioid use after surgery. These modifiable risk factors could be included in a comprehensive approach to identify patients at higher risk of persistent opioid use and opioid-induced ventilatory impairment. However, it should be noted that this evidence was of critically low quality according to the AMSTAR 2 checklist.\u003c/p\u003e\n\u003cp\u003ePriority 2 of the Levy consensus (\u0026ldquo;Consider optimising management of pre-operative pain and psychological risk-factors before surgery, including weaning of opioids where possible. Ensure realistic expectations of postoperative pain control, both in hospital and after discharge\u0026rdquo;) has three included SRs that provide evidence to support it. First of all, the SR by Horn \u003cem\u003eet al. (2020)\u003c/em\u003e concluded that addressing the psychological needs of patients through preoperative education can decrease acute postoperative pain, and therefore decrease the need for opioid consumption. Additionally, the SR by Powell \u003cem\u003eet al. (2016)\u003c/em\u003e found evidence that suggested preoperative psychological preparation may be beneficial for various outcomes, such as postoperative pain, behavioural recovery, negative affect and length of stay in hospital. However, the strength of evidence they found was insufficient, thus they recommended that further research is required to support this. Finally, the SR by Sobol-Kwapinska \u003cem\u003eet al. (2016)\u003c/em\u003e analysed the relations between presurgical psychological factors and acute postoperative pain. They identified numerous psychological variables that could be considered for optimising preoperative psychological risk factors before surgery, as recommended by Levy \u003cem\u003eet al. (2020)\u003c/em\u003e. The quality of evidence according to the AMSTAR 2 checklist was noted to be critically low for the SRs by Horn \u003cem\u003eet al.\u003c/em\u003e \u003cem\u003e(2020)\u0026nbsp;\u003c/em\u003eand Sobol-Kwapinska \u003cem\u003eet al. (2016)\u003c/em\u003e, but was high for the Powell \u003cem\u003eet al. (2016)\u003c/em\u003e SR.\u003c/p\u003e\n\u003cp\u003eBaamer \u003cem\u003eet al. (2022)\u003c/em\u003e provided evidence for priority 3 of the Levy consensus (\u0026ldquo;provision of opioid analgesia should be guided by functional outcomes, rather than unidimensional pain scores alone\u0026rdquo;) by challenging the validity and reliability of unidimensional tools to quantify acute postoperative pain. They also discovered that studies on functional outcomes assessment tools were scarce, and therefore proposed more research is necessary to assess the validity and reliability of such tools. The quality of this SR was low, according to the AMSTAR 2 tool. Thus, future research of a higher quality could be beneficial to further support priority 3 of the Levy consensus.\u003c/p\u003e\n\u003cp\u003ePriority 4 of the Levy consensus (\u0026ldquo;multimodal analgesia should be optimised and patients educated about the use of non-pharmacological and non-opioid analgesia to reduce the amount and duration of opioids required to restore function\u0026rdquo;) was supported through evidence from the SR by Martinez \u003cem\u003eet al. (2017)\u003c/em\u003e. This paper concluded that a multimodal regimen of non-opioid analgesics was superior to solitary use of a single non-opioid analgesia in reducing acute postoperative pain and morphine consumption. The supplementary material of this SR was unavailable, resulting in full quality appraisal being unachievable. More research could be done to further assess multimodal analgesic regimens to increase the validity of this recommendation from Levy \u003cem\u003eet al. (2020)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eThere are two SRs found through the methodology of this overview that provide evidence for the 6\u003csup\u003eth\u003c/sup\u003e priority of the Levy consensus (\u0026ldquo;a patient-centred approach should be used to limit the number of tablets and the duration of usual discharge opioid prescriptions, typically to less than a week\u0026rdquo;). Arwi and Schug \u003cem\u003e(2020)\u003c/em\u003e suggest that the current opioid prescribing practices could be improved. The studies they analysed showed that discharge opioids contribute to prolonged opioid use. However, more high-quality research with comparable outcomes is needed. Additionally, the SR by Feinberg \u003cem\u003eet al. (2018)\u003c/em\u003e reported that surgical patients are using substantially less opioid than prescribed, leading to excess opioids that may be used inappropriately by patients or others. The authors agreed that strategies and clinical practice guidelines are needed to better educate prescribers and help standardise postoperative opioid prescriptions. It should be noted that both these SRs were of critically low quality according to the AMSTAR 2 tool. It would be beneficial for research of a higher quality be carried out to further support the Levy consensus.\u003c/p\u003e\n\u003cp\u003eThe 10\u003csup\u003eth\u003c/sup\u003e priority of the Levy consensus (\u0026ldquo;patients should be advised on safe storage and disposal of unused opioids and directed to avoid opioid diversion to other individuals (e.g. sharing with friends and family)\u0026rdquo;) was also supported by the Arwi and Schug \u003cem\u003e(2020)\u003c/em\u003e SR. This paper reported that a lack of patient education regarding safe storage and disposal of opioids contributes to the increasing rate of opioid misuse, diversion and unintended persistent opioid use. However, the authors recommend that more high-quality research is needed on this topic. The SR by Bicket \u003cem\u003eet al. (2017)\u003c/em\u003e provides further evidence for the 10\u003csup\u003eth\u003c/sup\u003e priority. This paper concluded that postoperative opioid prescriptions often go unused, unlocked and undisposed, leading to a reservoir of opioids that contribute to the non-medical use of these products. Although both these SRs are of critically low quality according to the AMSTAR 2 checklist, they still provide important evidence that supports the 10\u003csup\u003eth\u003c/sup\u003e priority of the Levy consensus.\u003c/p\u003e\n\u003cp\u003eThe SR by Lamplot \u003cem\u003eet al. (2021)\u003c/em\u003e provides further evidence for priority 10 of the Levy consensus. They found that opioids are overprescribed for acute postoperative pain, and baseline rates of surplus opioid disposal are low. Furthermore, their results showed that drug disposal kits or bags help to significantly increase these rates. Due to the supplementary material being unavailable, we could not fully assess the quality of this SR. However, it provides valuable evidence for future strategies to increase the safe disposal of unused opioids.\u003c/p\u003e\n\u003cp\u003eWith regards to the Forget consensus, the 1\u003csup\u003est\u003c/sup\u003e priority (\u0026ldquo;the presence of a Pain Management, Analgesia or Opioid Stewardship Steering Committee, with multidisciplinary representation from Key Stakeholders is a priority in the context of acute pain, especially in the hospital\u0026rdquo;) has one included SR that provides supporting evidence \u003cem\u003e(Wetzel et al., 2018)\u003c/em\u003e. Their results showed evidence that clinician-mediated and organisation-level interventions are effective at reducing postoperative opioid prescribing. The quality of this SR was critically low. However, it provides useful evidence to aid the development of an evidence-based clinical practice guidelines.\u003c/p\u003e\n\u003cp\u003eFinally, Albrecht \u003cem\u003eet al. (2019)\u003c/em\u003e found that there is overall low certainty of evidence that high-dose intraoperative opioids in patients under general anaesthesia increases pain scores and contributes to hyperalgesia in the postoperative period when compared to low-dose regimen. However, they proposed that additional robust methodology trials could better define the impact of each opioid regime on hospital and health-system recourses. This agrees with priority 4 of the Forget consensus (\u0026ldquo;policies should be developed providing guidelines on maximum doses and duration of treatment for high-risk medications such as opioids and high-risk combinations\u0026rdquo;) by suggesting more trials should be undertaken in order to help develop such policies. The quality of the Albrecht \u003cem\u003eet al. (2019)\u003c/em\u003e SR was low according to the AMSTAR 2 checklist.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eImplications of Findings for Future Research\u003c/h2\u003e\n\u003cp\u003eThe number of drug-related deaths has vastly risen over the past few decades in the UK. According to the National Drug-Related Deaths Database (NDRDD) for Scotland, there were 1,209 deaths in 2018 that were drug related in Scotland. Opioids were implicated in 77% of these deaths \u003cem\u003e(Public Health Scotland, 2022)\u003c/em\u003e.\u0026nbsp;This is a significant increase from 2017, when there were 867 drug-related deaths in Scotland. In England and Wales, there were 3,756 drug-related deaths in 2018, a 16% increase from 2017 \u003cem\u003e(Office for National Statistics, 2021)\u003c/em\u003e. The rise in drug-related deaths is thought to be due to the increased availability and misuse of prescription and illicit opioids due to irrational prescribing, amongst other factors. There are concerns that the UK is closely following the trends of the devastating opioid epidemic seen in the USA. A solution to the contributing factor of liberal opioid prescribing for acute postoperative pain could be the implementation of national guidance and protocols.\u003c/p\u003e\n\u003cp\u003eThe Levy and Forget consensuses provide a strong framework for such protocols \u003cem\u003e(Levy et al., 2020; Forget et al., 2022)\u003c/em\u003e. They are predominantly expert opinion based. Historically, medicine was based on the consensus of experts and their opinions on best practices. Though expert opinion is a highly regarded and useful method of gathering information, it is more valid when used concomitant with evidence-based literature for the creation of healthcare policies and protocols \u003cem\u003e(Tonelli, 1999)\u003c/em\u003e. Further research is required to provide evidence of a higher quality to support these consensus statements.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eStrengths \u0026amp; Limitations\u003c/h2\u003e\n\u003cp\u003eThis overview included SRs of varying settings that covered a range of topics regarding rational opioid prescribing, enabling the concise evaluation and summarisation of literature related to the ten priorities of the Levy consensus \u003cem\u003e(Levy et al. 2021)\u0026nbsp;\u003c/em\u003eand the ten priorities of the Forget consensus \u003cem\u003e(Forget et al., 2022)\u003c/em\u003e. It therefore offers valuable insight into the evidence behind the two consensuses that are predominantly based on expert opinion. Furthermore, this overview was conducted in accordance with the Cochrane Handbook for the Systematic Review of Interventions \u003cem\u003e(Pollock et al., 2022)\u003c/em\u003e, which is well-known and well-used guidance, thus increasing reliability.\u003c/p\u003e\n\u003cp\u003eThere are several limitations of this overview. Firstly, there was one SR that could not be accessed for full-text analysis which may have offered valuable evidence \u003cem\u003e(Zorrilla-Vaca et al., 2022)\u003c/em\u003e. Additionally, the supplementary material of three included SRs was not available, despite requesting access from the authors, resulting in full quality appraisals being incomplete \u003cem\u003e(Lamplot et al., 2021; Martinez et al., 2017; Wetzel et al., 2018)\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003eThere was significant heterogeneity amongst the SRs regarding interventions, outcome measures, and quality evaluation method, with only four out of the 12 included SRs including meta-analysis. This meant that the SRs were not comparable. However, they provided valuable evidence for the aim of this overview.\u003c/p\u003e\n\u003cp\u003eFinally, another limitation of this overview is that the included papers were from a wide range of countries. Though this may provide useful information that could shape future rational opioid prescribing protocols, it may not be applicable to UK guidance.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this overview of SRs provides valuable insight into the evidence behind the Levy \u003cem\u003eet al.\u003c/em\u003e and Forget \u003cem\u003eet al.\u003c/em\u003e consensus statements on rational opioid prescribing. However, there is a dearth of research that is required to implement valid and reliable nation opioid prescribing protocols. This overview found that there are not enough papers with high quality evidence to support the Levy \u003cem\u003eet al.\u003c/em\u003e and Forget \u003cem\u003eet al.\u003c/em\u003e consensus statements. The papers that were identified were mainly of low quality. Therefore, more research of a higher quality is required. The liberal prescribing of opioids for acute postoperative pain requires urgent attention. For now, it could be greatly beneficial to implement the recommendations given in the Levy \u003cem\u003eet al.\u003c/em\u003e and Forget \u003cem\u003eet al.\u003c/em\u003e consensus statements. The consensus papers provide guidance based on the consensus of expert opinion that is based on the best available evidence. However, efforts to further analyse interventions that aim to reduce the rates of opioid prescribing and their adverse effects should continue.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval:\u0026nbsp;\u003c/strong\u003eDue to the nature of this literature-based project, no ethics approval was required. However, each of the systematic reviews included state the ethics considerations and approval that they required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e Forget P received speaker/advisory board fees from Grunethal and Oncomfort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e The authors received no specific funding for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Contributions:\u0026nbsp;\u003c/strong\u003eCM was the primary author of this overview. CM and RT screened the identified articles. CM and RG appraised the included articles. PF gave continuous support, guidance and valuable input throughout the process of conducting and writing of this overview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlbrecht, E., Grape, S., Frauenknecht, J., Kilchoer, L., Kirkham, K. (2019). Low- versus highdose intraoperative opioids: a systematic review with meta-analyses and trial sequential analyses. \u003cem\u003eActa Anaesthesiol Scand, 64(1)\u003c/em\u003e, 6-22. https://doi.org/10.1111/aas.13470\u003c/li\u003e\n \u003cli\u003eArwi, G .A., Schug, S. A. (2020). Potential for harm associated with discharge opioids after hospital stay: a systematic review. \u003cem\u003eDrugs, 80\u003c/em\u003e, 573\u0026ndash;85. https://doi.org/10.1007/s40265-020-01294-z\u003c/li\u003e\n \u003cli\u003eBaamer, R. M., Iqbal, A., Lobo, D. N., Knaggs, R .D., Levy, N. A., Toh, L. S. (2022). 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C., Hattingh, K., Knaggs, R. D., Mariano, E. R., Pelosi, P., Scott, M. J., Lobo, D. N. and Macintyre, P. E. (2021). An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients. \u003cem\u003eAnaesthesia\u003c/em\u003e, \u003cstrong\u003e\u003cem\u003e76\u003c/em\u003e\u003c/strong\u003e, 520-536. https://doi.org/10.1111/anae.15262\u003c/li\u003e\n \u003cli\u003eLevy, N., Sturgess, J., Mills. (2018). \u0026ldquo;Pain as the fifth vital sign\u0026rdquo; and dependence on the \u0026ldquo;numerical pain scale\u0026rdquo; is being abandoned in the US: why?. \u003cem\u003eBr J Anaesth\u003c/em\u003e, \u003cem\u003e120(3)\u003c/em\u003e, 435-438, doi: https://doi.org/10.1016/j.bja.2017.11.098\u003c/li\u003e\n \u003cli\u003eLorenz, R. C., Matthias, K., Pieper, D., Wegewitz, U., Morche, J., Nocon, M., Rissling, O., Schirm, J., Jacobs, A. (2019). A psychometric study found AMSTAR 2 to be a valid and moderately reliable appraisal tool. \u003cem\u003eJ Clin Epidemiol\u003c/em\u003e, \u003cem\u003e114\u003c/em\u003e, 133-140. doi: 10.1016/j.jclinepi.2019.05.028\u003c/li\u003e\n \u003cli\u003eMartinez, V., Beloeil, H., Marret, E., Fletcher, D., Ravaud, P., Trinquart, L. (2017). Non-opioid analgesics in adults after major surgery: systematic review with network meta-analysis of randomized trials. \u003cem\u003eBr J Anaesth, 118(1)\u003c/em\u003e, 22-31. https://doi.org/10.1093/bja/aew391\u003c/li\u003e\n \u003cli\u003ePage, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hr\u0026oacute;bjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., McGuinness, L. A., Stewart, L. A., Thomas, J., Tricco, A. C., Welch, V. A., Whitling, P., Moher, D. (2021). 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National drug related death database (Scotland): analysis of deaths occurring in 2017 and 2018. \u003cem\u003ePublic Health Scotland\u003c/em\u003e. Available at: https://publichealthscotland.scot/publications/national-drug-related-death-database-scotland/the-national-drug-related-deaths-database-scotland-report-analysis-of-deaths-occurring-in-2017-and-2018/ [Accessed 9 December 2022]\u003c/li\u003e\n \u003cli\u003eSackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn\u0026apos;t. \u003cem\u003eBMJ\u003c/em\u003e, \u003cem\u003e312(7023)\u003c/em\u003e, 71-2. doi: 10.1136/bmj.312.7023.71\u003c/li\u003e\n \u003cli\u003eSchug, S. A., Palmer, G. M., Scott, D. A., Alcock, M., Halliwell, R., Mott, F. D. (2020). Acute pain management: scientific evidence (fifth edition). \u003cem\u003eAustralian and New Zealand College of Anaesthetists and Faculty of Pain Medicine\u003c/em\u003e. Available at: https://www.anzca.edu.au/resources/college-publications/acute-pain-management/apmse5.pdf [Accessed 9 November 2022]\u003c/li\u003e\n \u003cli\u003eShea, B. J., Reeves, B. C., Wells, G., Thuku, M., Hamel, C., Moran, J., Moher, D., Tugwell, P., Welch, V., Kristjansson, E., Henry, D. A. (2017). AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. \u003cem\u003eBMJ\u003c/em\u003e, \u003cem\u003e358\u003c/em\u003e, j4008. doi: 10.1136/bmj.j4008\u003c/li\u003e\n \u003cli\u003eSobol-Kwapinska, M., Babel, P., Plotek, W., Stelcer, B. (2016). Psychological correlates of acute postsurgical pain: a systematic review and meta-analysis. \u003cem\u003eEur J Pain\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e, 1573-1586. https://doi.org/10.1002/ejp.886\u003c/li\u003e\n \u003cli\u003eTonelli, M. R. (1999). In defense of expert opinion. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e74(11)\u003c/em\u003e, 1187-92. doi: 10.1097/00001888-199911000-00010\u003c/li\u003e\n \u003cli\u003eWetzel, M., Hockenberry, J., Raval, M. V. (2018). Interventions for postsurgical opioid prescribing: a systematic review. \u003cem\u003eJAMA Surg\u003c/em\u003e, \u003cem\u003e53(10)\u003c/em\u003e, 948\u0026ndash;54. doi:10.1001/jamasurg.2018.2731\u003c/li\u003e\n \u003cli\u003eZorrilla-Vaca, A., Mena, G. E., Ramirez, P. T., Lee, B. H., Sideris, A., Wu, C. L. (2022). Effectiveness of postoperative opioid educational initiatives: a systematic review and meta-analysis. \u003cem\u003eAnesth Analg\u003c/em\u003e, \u003cem\u003e134(5)\u003c/em\u003e, 940-951 doi: 10.1213/ANE.0000000000005634\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"opioid, acute pain, postsurgical, postoperative","lastPublishedDoi":"10.21203/rs.3.rs-2873258/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2873258/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNational guidelines for rational opioid prescribing for acute postoperative pain are needed to optimise postoperative pain control and function whilst minimising opioid-related harm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis overview of systematic reviews aims to summarise and critically assess the quality of systematic reviews related to the 20 previously published recommendations (ten relevant at patient and prescriber levels and ten at a system / Public Health level). It also aims to identify gaps in research that require further efforts to fill these in order to augment the evidence behind creating national guidelines for rational opioid prescribing for acute postoperative pain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA systematic database search using PubMed/MEDLINE and Cochrane was conducted in November 2022. Furthermore, reference lists were reviewed. All identified systematic reviews were assessed for eligibility. Data from each study was extracted using a pre-standardised data extraction form. The methodological quality of the included reviews was assessed by two independent reviewers using the AMSTAR 2 checklist. Descriptive synthesis of the results was performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 12 papers were eligible for analysis. Only eight out of the total 20 prioritised recommendations had systematic reviews that provided evidence related to them. These systematic reviews were most commonly of critically low quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe consensus papers provide guidance and recommendations based on the consensus of expert opinion that is based on the best available evidence. However, there is a lack of evidence supporting many of these consensus statements. Efforts to further analyse interventions that aim to reduce the rates of opioid prescribing and their adverse effects should therefore continue.\u003c/p\u003e","manuscriptTitle":"Opioid Prescribing for Acute Postoperative Pain: An Overview of Systematic Reviews","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-05-18 13:43:43","doi":"10.21203/rs.3.rs-2873258/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-06-20T04:05:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-06-06T15:53:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"f7baa357-8b1a-44d5-b20a-e0551b847e21","date":"2023-06-03T02:11:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-06-02T16:52:11+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-06-02T16:36:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2023-05-16T11:01:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-05-16T11:00:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Anesthesiology","date":"2023-04-28T13:32:50+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-anesthesiology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bane","sideBox":"Learn more about [BMC Anesthesiology](http://bmcanesthesiol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bane","title":"BMC Anesthesiology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c6632730-4b37-487c-9eb5-ae49f6323a81","owner":[],"postedDate":"May 18th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-09-07T15:16:34+00:00","versionOfRecord":{"articleIdentity":"rs-2873258","link":"https://doi.org/10.1186/s12871-023-02243-5","journal":{"identity":"bmc-anesthesiology","isVorOnly":false,"title":"BMC Anesthesiology"},"publishedOn":"2023-08-30 15:09:42","publishedOnDateReadable":"August 30th, 2023"},"versionCreatedAt":"2023-05-18 13:43:43","video":"","vorDoi":"10.1186/s12871-023-02243-5","vorDoiUrl":"https://doi.org/10.1186/s12871-023-02243-5","workflowStages":[]},"version":"v1","identity":"rs-2873258","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2873258","identity":"rs-2873258","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}