ZACHARY BLICKLEY, BS
Smoking increases postoperative opioid usage and pain scores across different surgical specialties and procedures.
Smokers have a significantly increased risk of developing new persistent opioid use after both major and minor procedures
Chronic smoking can downregulate the hypothalamic-pituitary-adrenal (HPA) axis, decreasing the analgesic effects of the HPA axis to physiologic stress.
Smoking increases the risk of both acute and chronic pain after surgery.
Smoking cessation only decreases postoperative opioid requirements and pain scores if cessation occurs at least 1 month prior to surgery.
The opioid epidemic continues to be one of the largest issues confronting the United States healthcare system. Drug overdose is now the leading cause of accidental death in the United States, and in 2021 the number of annual drug overdoses eclipsed 100,000 victims . In an attempt to address this issue, attention has turned to optimize opioid prescribing by physicians. Prescribers should use evidence-based methods while evaluating patients for risk factors of opioid use disorder (OUD). One major risk factor for OUD is tobacco smoking, as there is substantial evidence surrounding correlations between pain, nicotine, and smoking (Figure 1) . It has been shown that smoking increases postoperative opioid use and pain scores, making it one of the strongest risk factors for physicians to consider when prescribing opioids [3,4,5,6].
The increase in opioid usage after surgery in smokers has been demonstrated across multiple surgical fields including general surgery, orthopedics, and otolaryngology [3,4,5,6]. A current smoker is independently associated with a 27 morphine equivalent dose per day when compared to a patient who has never smoked . Additionally, those reporting higher pack-years have a less than expected decline in opioid consumption 3 months after surgery . As a result, this patient population is at an increased risk to develop new, persistent opioid use after both minor and major procedures . This may be due to the fact that patients who smoke experience higher preoperative and postoperative pain scores. Mean pain scores for current smokers average 2.89 points higher than their non-smoking peers . These findings are consistent with findings that smoking increases the risk of developing both acute and chronic pain at baseline, regardless of any experienced surgical procedure [8,10,11]. In the postoperative setting, studies have shown that smoking is associated with functional interference in patients receiving treatment for chronic pain . Overall, smoking creates a unique challenge for prescribing physicians to manage post-surgical, acute, and chronic pain.
Smoking is believed to increase chronic pain through a number of mechanisms. One review proposed that the hypothalamic-pituitary-adrenal (HPA) axis plays a role in increased pain sensitivity in smokers. It suggested that acute administration of nicotine activates the HPA axis which itself causes a decrease in pain perception. In chronic smokers, however, the HPA axis is down-regulated. As a result of this lowered activation, when exposed to physiologic stress, chronic smokers experience increased pain levels when compared to their non-smoking counterparts . Despite this baseline pain hypersensitivity, acute administration of nicotine produces temporary analgesic effects resulting in smoking and pain interacting in a positive feedback mechanism where increased pain causes the patient to smoke more which maintains their tobacco addiction [2,13]. Furthermore, smoking prevalence among adults with opioid dependence far exceeds that of the general population, and in these patients, smoking cessation efforts are only one-quarter as effective when compared to the non-smoking population. These collective findings demonstrate that opioid dependence increases the severity and prevalence of nicotine dependence, further feeding into the positive feedback mechanism of pain hypersensitivity and resultant chronic pain .
Lastly, when considering counseling patient’s on smoking cessation prior to surgery, it is important to understand the effect of the timing of cessation relative to surgery. Kim et al. found that postoperative opioid requirements decreased with longer durations of smoking cessation (Figure 2) . Another finding of this study was that smokers who ceased smoking within 1 month of surgery actually had increased opioid requirements and pain scores when compared to non-smokers and patients who had ceased smoking more than one month prior to surgery . Therefore, when counseling patients on preoperative smoking sessions, ideally smoking cessation has been achieved over a month before surgery, otherwise, patients may experience a rebound of increased postoperative opioid requirement.
Overall, smoking poses a unique challenge to providers managing postoperative pain. Chronic smokers report increased pain levels and have an increased risk of developing new persistent opioid use after surgery. Additionally, if smoking cessation is to be attempted prior to surgery, it is important that smoking ceases more than one month prior to surgery so as to avoid a rebound increase in postoperative opioid requirements and pain levels. These competing interests leave providers in a tough situation when trying to manage their patients. Future research should address the best way to manage pain in the smoking population after surgery. Additionally, future studies may focus on whether multimodal pain management strategies are also effective in the smoking population to decrease chronic opioid usage.
1. Drug overdose deaths in the U.S. top 100,000 annually. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm. Published November 17, 2021. Accessed June 29, 2022.
2. Ditre JW, Brandon TH, Zale EL, Meagher MM. Pain, nicotine, and smoking: Research findings and mechanistic considerations. Psychological Bulletin. 2011;137(6):1065-1093. doi:10.1037/a0025544.
3. Canseco JA, Chang M, Karamian BA, et al. Predictors of prolonged opioid use after lumbar fusion and the effects of opioid use on patient-reported outcome measures. Global Spine Journal. 2021:219256822110419. doi:10.1177/21925682211041968.
4. Wojahn RD, Bogunovic L, Brophy RH, et al. Opioid consumption after knee arthroscopy. Journal of Bone and Joint Surgery. 2018;100(19):1629-1636. doi:10.2106/jbjs.18.00049.
5. Kim C-S, Sim JH, Kim Y, Choi S-S, Kim D-H, Leem J-G. Association between postoperative opioid requirements and the duration of smoking cessation in male smokers after laparoscopic distal gastrectomy with gastroduodenostomy. Pain Research and Management. 2021;2021:1-7. doi:10.1155/2021/1541748.
6. Zheng Z, Riley CA, Kim M, Sclafani A, Tabaee A. Opioid prescribing patterns and usage after rhinologic surgery: A systematic review. American Journal of Otolaryngology. 2020;41(4). doi:10.1016/j.amjoto.2020.102539.
7. Hooten MW, Shi Y, Gazelka HM, Warner DO. The effects of depression and smoking on pain severity and opioid use in patients with chronic pain. Pain. 2011;152(1):223-229. doi:10.1016/j.pain.2010.10.045.
8. Montbriand JJ, Weinrib AZ, Azam MA, et al. Smoking, pain intensity, and opioid consumption 1–3 months after major surgery: A retrospective study in a hospital-based Transitional Pain Service. Nicotine & Tobacco Research. 2017;20(9):1144-1151. doi:10.1093/ntr/ntx094.
9. Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery. 2017;152(6). doi:10.1001/jamasurg.2017.0504.
10. Parkerson HA, Zvolensky MJ, Asmundson GJG. Understanding the relationship between smoking and pain. Expert Review of Neurotherapeutics. 2013;13(12):1407-1414. doi:10.1586/14737175.2013.859524.
11. Holley AL, Law EF, Tham SW, et al. Current smoking as a predictor of chronic musculoskeletal pain in young adult twins. The Journal of Pain. 2013;14(10):1131-1139. doi:10.1016/j.jpain.2013.04.012.
12. Weingarten TN, Podduturu VR, Hooten WM, Thompson JM, Luedtke CA, Oh TH. Impact of tobacco use in patients presenting to a multidisciplinary outpatient treatment program for fibromyalgia. The Clinical Journal of Pain. 2009;25(1):39-43. doi:10.1097/ajp.0b013e31817d105e.
13. Shi Y, Weingarten TN, Mantilla CB, Hooten WM, Warner DO. Smoking and pain. Anesthesiology. 2010;113(4):977-992. doi:10.1097/aln.0b013e3181ebdaf9.
14. Parker MA, Streck JM, Sigmon SC. Associations between opioid and nicotine dependence in nationally representative samples of United States Adult Daily Smokers. Drug and Alcohol Dependence. 2018;186:167-170. doi:10.1016/j.drugalcdep.2018.01.024.