The risks associated with opioid analgesics in the chronic pain setting have been well documented, and many pain management physicians have initiated steps to reduce their overall use of these agents for long-term treatment.
Now, surgeons in multiple specialties have begun to pay greater attention to their prescribing of opioids for even the short-term management of postoperative pain, for fear that their use even during the relatively short, two- to three-day postsurgical recovery period could lead to problems of abuse and misuse in their patients long after they have left the operating room.
Although opioids are still considered first-line therapy for moderate to severe postoperative pain following many procedures, some surgeons are implementing various strategies both pre- and perioperatively that are designed to reduce their patients’ reliance on opioids postoperatively. The result has been, in many cases, a significant reduction in opioid prescribing at surgical centers.
“I’ve undergone a wholesale change in the way I manage patients’ pain postoperatively,” noted Scott Sigman, MD, chief of orthopedic surgery at Lowell General Hospital in Massachusetts. “Obviously, we’ve always been looking at ways to try to reduce that pain and get them through the healing process. But over the past two years, I’ve watched the opioid crisis develop, and I’ve seen our children dying in the streets, literally and figuratively. I’ve realized that it is incumbent upon all surgeons, all physicians really, to get our patients through the healing experience without giving them another problem by creating a substance abuse issue down the line.”
Lowell is one of many U.S. cities dealing with an epidemic of opioid drug abuse. Recent surveys suggest that 5 million Americans are affected by opioid dependence, and half of the opioid-related overdose deaths across the country have been linked to prescription drugs, as opposed to “street” or so-called “recreational” drugs such as heroin (2011 National Survey on Drug Use and Health).
Typically, surgeons performing procedures that often result in moderate to severe postoperative pain—such as orthopedic, thoracic and even cosmetic surgeries—will prescribe an opioid analgesic for a 24- to 72-hour period in order to manage that pain. Although such short-term opioid use may not directly lead to future abuse and misuse in most patients, surgeons say it can be problematic in patients with a history of substance abuse.
“I’ve been an orthopedic surgeon for 25 years, and it’s very rare that a patient will come to me and say, ‘You know, I have a history of substance abuse. What are my options if I have any pain after my surgery?’” Dr. Sigman said. “It’s up to the doctor to start that conversation.”
Although professional societies representing surgeons of several subspecialties have developed guidelines on postoperative prescribing of opioids, some surgeons say they are not specific enough in terms of patient selection (and exclusion) criteria or in recommending alternative modalities. In recent years, however, several multimodal strategies have emerged that are designed to assist surgeons seeking to reduce their patients’ reliance on opioids postoperatively.
Surgeons such as Dr. Sigman, for example, have begun using patient pain contracts, a concept that has been used widely within the specialty of pain medicine for several years. These contracts effectively formalize the patient education process with regard to pain management, and engage the patients in their own pain care, by asking them to comply with physician requirements regarding prescription drug use and routine drug monitoring.
Eric Haas, MD, of Colorectal Surgical Associates in Houston, has adopted the enhanced recovery after surgery (ERAS) protocol for use in the majority of his patients. The goal of ERAS is to enhance patient recovery following surgery by preventing the problems associated with an exaggerated inflammatory reaction to a procedure, such as poor healing, infective complications and organ dysfunction. Pioneered for colorectal surgery in the late 1990s, ERAS protocols incorporate minimally invasive surgical techniques, increased use of short-acting anesthetics, ileus control, and the use of invasive monitoring and intensive care treatment. The ERAS approaches have gained greater acceptance in the United States and Europe across a number of surgical specialties, and they have been associated with improvements in postoperative length of stay and morbidity.
One of the hallmarks of the ERAS approach is reduced reliance on opioids for postoperative pain management. Surgeons implementing these strategies thus use nonsteroidal anti-inflammatory drugs and emerging alternatives such as bupivacaine liposome (Exparel, Pacira) in patients whenever possible.
“With minimally invasive surgery, there’s less pain, earlier recovery and shorter length of stay following procedures,” Dr. Haas explained. “But even then, we’re only dealing with half the equation. What’s missing is addressing the entire encounter with the patient through to post-op recovery.”
What effect such changes in approach have had on overall opioid use for postoperative pain is difficult to gauge, given that there are no studies measuring prescribing patterns for surgery as a global discipline. However, studies of opioid use among surgical subspecialties published this year highlight some interesting trends.
A study published by a team of hand surgeons (J Hand Surg Am 2015;40:341-346) found that the inclusion of a pink reminder card in the patient file encouraged surgeons to discuss postoperative pain options with patients before surgery and recommend alternatives to opioids. When this discussion occurred—at which time patients were apprised of the risks associated with opioids—the number of opioid prescriptions written by the team dropped by 15%. Similarly, a recent survey of dermatologic surgeons found that 64% were prescribing opioids for postoperative pain in fewer than 10% of their surgical cases (Dermatol Surg2014;40:906-911).
“Physicians have been getting a bad rap in many ways, with people saying, ‘Oh, they are prescribing too many drugs,’” Dr. Sigman said. “But there’s a real fine line here. We want to be able to operate on our patients. We want to be able to heal them and make sure they’re comfortable and not in a tremendous amount of pain. There needs to be education across all fronts, for physicians on the proper administration of narcotics and adherence to pain protocols, and for patients and their families on the options available and the risks and issues involved. But we’re starting to see a change now. I am having conversations with the patients in my practice about pain management, and these are discussions I wouldn’t have had even two years ago.”
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