Author: Karen Blum
With surgical recovery presenting the possibility that patients will become dependent on opioids, speakers at the 2019 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons discussed tips to reduce opioid prescribing and ways to manage pain without opioids in enhanced recovery pathways.
While 90% of patients taken to ORs are opioid-naive, about 6% of those undergoing minor and major procedures who are prescribed opioids for pain management continue to use the drugs past their normal recovery, said Chad Brummett, MD, an associate professor of anesthesiology and the director of the Division of Pain Research at the University of Michigan, in Ann Arbor (JAMA Surg 2017;152:e170504). Additional studies have found persistent rates of opioid use among 13% of spine and hand surgery patients, 10% of cancer surgery patients, 8% of knee replacement patients, 4% of hip replacement patients, and nearly 5% of teens and adolescents undergoing elective pediatric operations, he noted.
Dr. Brummett and his colleagues with the Michigan OPEN (Opioid Prescribing Engagement Network) have been working to develop a preventive approach to the opioid epidemic, studying factors that place patients at risk for opioid misuse and dependence and developing strategies to decrease opioid prescribing.
The group has identified several factors that increase patients’ risk for chronic opioid use. These include chronic pain conditions, where patients may take advantage of opioids prescribed for pain after surgery and use them to manage other pain issues, anxiety, mood disorders and history of substance abuse and tobacco use.
The amount prescribed also matters. Michigan state data indicate that one of the strongest predictors of how much opioid a person used after hospital discharge is the amount prescribed, he said (JAMA Surg 2018;154:e184234). For every additional pill prescribed, patients use an extra half pill just because they have it. Michigan OPEN changed its guidelines for laparoscopic cholecystectomies, to reduce its prescribing of opioids from 50 to 15 pills, with no change in calls for refills or patient-reported pain scores.
“As we prescribed less, people took less,” Dr. Brummett said. Based on new data, the recommendations have been further dropped for laparoscopic cholecystectomies (now 10 pills) and other procedures. For more information, see www.opioidprescribing.info.
Physicians need to change the mindset of prescribing patients enough medication so they don’t run out, he said. “Giving patients 90 pills for convenience isn’t going to decrease [the] refill rate. It’s not going to improve satisfaction; it’s not going to improve pain. What it will do is increase their use and their potential for long-term ill effects.”
Dr. Brummett offered some practical tips for postoperative prescribing. Educate your patients and set expectations. Just telling them that surgery hurts will help, he said. Encourage the use of acetaminophen, ibuprofen and other nonopioid treatments. Avoid coprescribing benzodiazepines and sedatives. If you must prescribe an opioid, check your prescription drug monitoring program before doing so. When prescribing opioids for new patients, he said, prescribe only one short-acting opioid; do not use long-acting opioids; don’t give people a prescription the day before surgery as a convenience; and prescribe naloxone for patients at high risk for overdose.
Postoperative pain is the most feared aspect of operations, and is inadequately treated in about 50% of cases, said Julie K. Thacker, MD, FACS, FACRS, an associate professor of surgery at Duke University, in Durham, N.C., in another presentation. Optimal analgesia after surgery should maximize patient comfort while promoting the fastest functional recovery, she said, “and we know a lot of the drugs we use to manage pain don’t allow for both of those things to happen.”
Surgeons most often start pain management with opioids, Dr. Thacker said. If that doesn’t work, they add more opioids or progress to giving patients control of opioids and then looking at other options. Instead, she said, we need to flip this around to start with other drugs and only use opioids if they are needed as a rescue medication. To embrace this concept, she said, surgeons need to recognize that most pain is multifactorial, and no single analgesic agent can treat all types of pain. Multimodal analgesia, or MMA, combines two or more analgesics that act on different mechanisms, producing synergistic pain relief. “The main goal is to try and decrease the adverse effects that are possible with opioids,” she said. “It’s not necessarily to make a patient pain-free.”
Postoperative pain can result from a number of factors including visceral pain and cortical responses as well as individual patient responses, Dr. Thacker explained. Work with your anesthesiologists to determine which pain pathways will be affected by your procedures, and discuss what drugs to use with different profiles to target sources of pain. MMA should include preemptive analgesia to stop pain before it begins, she said.
In enhanced recovery pathways, “the greatest impacts are recognized when you have successful continuity across all phases of surgical care,” Dr. Thacker said. MMA requires talking with your anesthesiologists about the surgical stress you will be causing, and talking to patients about what their operations will entail. It should incorporate teamwork from the surgery clinic through the preoperative and postoperative areas and back to the clinic so everyone is on the same page about the analgesia plan. Intraoperatively, if something changes in your surgical planning, there may be an unexpected wound you weren’t anticipating, Dr. Thacker said. Tell the surgical team you are changing the surgical stress, and make sure medications are coordinated as needed.
In the postoperative/PACU setting, Dr. Thacker advised, educate and empower nurses to discuss what is being done for patient analgesia, how much drug they received in surgery, and what to do when blocks wear off. Make sure every care team member knows the plan and timing for recommended analgesia, and stick to your discharge plans. “Don’t back down, and don’t feel you have to give more opioid than you were planning unless something changed along the postoperative course,” she said.
While many patients say they want to have a postoperative pain score of 0, it helps to explain to them that if they take less opioids and have a pain score of 3 or 4, they can still function and have minimal side effects, added Timothy Miller, MD, an associate professor of anesthesiology and the director of the Perioperative Medicine Fellowship at Duke University Hospital, in Durham, N.C. He was a co-author of the American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on optimal analgesia within an ERP for colorectal surgery (Perioper Med [Lond] 2017;6:8).
A number of medications and regional anesthesia techniques beyond opioids are available to help manage patients’ pain around the time of surgery, said Dr. Miller, including nonsteroidal anti-inflammatory drugs, acetaminophen, gabapentinoids, IV lidocaine and ketamine, intrathecal morphine sulfate, and surgical transversus abdominis plane and other abdominal field blocks. Medical center teams should interpret evidence for these in light of their local experience, he said, choosing the blocks and pain management techniques that are right for them based on their unique patient populations and acute pain service.
Dr. Miller also shared medication plans used in the Duke ERPs for open and laparoscopic colorectal procedures. The plan for laparoscopic surgery, for example, includes giving preoperative celecoxib at 400 mg orally and gabapentin at 600 mg orally; using a spinal of 100 to 150 mcg morphine with 5 to 12.5 mg bupivacaine; adding TAP blocks at the end, with 266 mg liposomal bupivacaine (Exparel, Pacira) and 20 mL 0.5% bupivacaine at 40 mL total; and 1 g of IV acetaminophen at the end of the case. This is followed by around-the-clock postoperative ibuprofen, celecoxib and acetaminophen, he said.