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EMMA LIPSCHUTZ, MS
Drexel University College of Medicine
SUMMARY POINTS
Opioid-sparing pain management strategies for patients following bariatric surgery are necessary to reduce the risk of chronic opioid use.
Preemptive analgesia with gabapentinoids has been demonstrated to lower patient pain scores up to 24 hours following bariatric surgery.
Preoperative administration of gabapentin has a significant effect on decreasing opioid consumption postoperatively.
ANALYSIS
Background
Throughout the past three decades, opioids have played a significant role in many standard treatment protocols for postoperative acute and chronic pain (1). While each surgical specialty faces unique challenges in mitigating the postoperative pain experienced by their patient populations, prescribing patterns are of particular concern in the context of bariatric surgery since the chronic use of opioids following these procedures is estimated to be around 14% (2). One contributing factor to this staggering statistic may be that 87% of bariatric surgery patients have leftover prescriptions and over one third of these patients hold on to the excess pills rather than disposing of them (1). Collectively, these results indicate a need for alterations to the current pain management protocols for bariatric surgery patients and motivated health care providers to explore alternative treatment strategies.
A proposed solution has been the administration of preemptive analgesics to decrease the sensitization of the central nervous system to stimuli normally perceived as painful, subsequently decreasing the risk of hyperalgesia postoperatively (3). Gabapentinoids, including gabapentin and pregabalin, are one class of analgesics tested to fulfill this hypothesis. Initially developed as an anti-epileptic medication, gabapentinoids were discovered to also possess the ability to treat neuropathic pain by decreasing excitatory neurotransmitter release and proinflammatory cytokines (4,5). Research studies designed to evaluate the efficacy of various preemptive analgesic agents identified gabapentinoids as a successful candidate for decreasing patient pain scores, as approximated by the Visual Analog Scale (VAS), up to 48 hours following surgery (3). Additionally, gabapentin was shown to decrease postoperative opioid consumption (3,5). Taken together, these results suggest that the implementation of preoperative administration of gabapentinoids may improve patient outcomes postoperatively. However, these studies are generalizing the effects of these analgesic agents across all surgical specialties. As a result, further investigation of the role of gabapentinoids in the context of bariatric surgery is required.
Analysis
To assess the efficacy of gabapentin for managing postoperative pain following bariatric surgery, various systematic reviews and metanalyses have been conducted. Researchers have found that patients who received a single dose of gabapentin preoperatively reported a decreased pain score at various time points within the first twelve hours following surgery (4,6). Pregabalin demonstrated a similar effect to gabapentin. Additionally, studies revealed that administration of gabapentin or pregabalin decreased the consumption of opioids at six, twelve, and twenty-four hours postoperatively. (4,6). These results indicate that this class of analgesic may help to improve pain management techniques and decrease the prevalence of long-term opioid use seen in bariatric surgery patients. However, preoperative gabapentin failed to demonstrate a significant impact on the incidence of postoperative nausea and vomiting, dizziness, and/or headache following surgery (6). Therefore, further investigation is indicated to identify an agent that can effectively mitigate the occurrence of adverse events secondary to bariatric surgery.
As studies have continued to demonstrate the potential contributions gabapentinoids offer to opioid-sparing pain management strategies, gabapentin has been explored in the context of Bariatric Surgery Targeting Opioid Prescriptions (BSTOP). BSTOP is a multifaceted enhanced recovery after surgery (ERAS) approach designed by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program in 2019 to limit the prescription of opioids postoperatively by emphasizing regional anesthesia, patient education, and non-opioid treatments for pain management (7). A prospective study examining the implementation of BSTOP protocols concluded that postsurgical opioid consumption was decreased for patients following BSTOP compared to those who were not (7). Also, the addition of gabapentin to the BSTOP approach further lowered both inpatient and outpatient opioid use (7). This demonstrates that gabapentin can play a vital role in enhancing postoperative outcomes for patients following bariatric surgery.
Discussion
As the incidence of obesity continues to increase in the United States, bariatric surgery procedures have become common and effective treatments for these conditions (1). Therefore, it is imperative that appropriate measures are in place to optimize postsurgical outcomes for these patients. While various investigations have elucidated gabapentinoids as useful in promoting preemptive analgesia, current studies do not separate the effects of these agents by bariatric surgery procedure. It is possible that this analgesic technique may have varying results dependent on the surgical approach, but further investigation is required to analyze this phenomenon. Additionally, many of the studies did not separate the effects of gabapentinoids by dosage or timing of preoperative administration, indicating that further inquiry may be needed to better refine protocols for gabapentinoid and pregabalin use in the context of bariatric surgery.
REFERENCES
Lin A, Verhoeff K, Mocanu V, et al. Opioid prescribing practices following bariatric surgery: a systematic review and pooled proportion meta-analysis. Surg Endosc. 2023;37(1):62-74. doi:10.1007/s00464-022-09481-7
King WC, Chen JY, Belle SH, et al. Use of prescribed opioids before and after bariatric surgery: prospective evidence from a U.S. multicenter cohort study. Surg Obes Relat Dis. 2017;13(8):1337-1346. doi:10.1016/j.soard.2017.04.003
Xuan C, Yan W, Wang D, et al. Efficacy of preemptive analgesia treatments for the management of postoperative pain: a network meta-analysis. Br J Anaesth. 2022;129(6):946-958. doi:10.1016/j.bja.2022.08.038
Hung KC, Wu SC, Chiang MH, et al. Analgesic Efficacy of Gabapentin and Pregabalin in Patients Undergoing Laparoscopic Bariatric Surgeries: a Systematic Review and Meta-analysis. Obes Surg. 2022;32(8):2734-2743. doi:10.1007/s11695-022-06109-6
Hah J, Mackey SC, Schmidt P, et al. Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort: A Randomized Clinical Trial. JAMA Surg. 2018;153(4):303–312. doi:10.1001/jamasurg.2017.4915
Tubog TD, Harmer CM, Bramble RS, Bayaua NE, Mijares M. Efficacy and Safety of Gabapentin on Postoperative Pain Management After Bariatric Surgery: A Systematic Review and Meta-Analysis. J Perianesth Nurs. 2023;38(2):322-330. doi:10.1016/j.jopan.2022.04.017
Seu R, Pereira X, Goriacko P, et al. Effectiveness of Bariatric Surgery Targeting Opioid Prescriptions (BSTOP) protocol on postoperative pain control. Surg Endosc. 2023;37(6):4902-4909. doi:10.1007/s00464-022-09646-4
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