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Treating post-surgical pain without opioids

July 09, 2019 | UCI Health
man in pain after shoulder surgery

There’s no denying that America is in the midst of an opioid epidemic, with more than 47,000 deaths in 2017 from overdoses on prescription opioids, heroin and illicitly manufactured fentanyl, a number greater than all U.S. traffic-related fatalities the same year.

Of those deaths, 36% involved prescription opioids, according to the Centers for Disease Control and Prevention. Although surgeons aren’t the only ones who prescribe opioid pain-relievers, new prescriptions by surgeons rose more than 18% between 2010 and 2016.

These striking numbers have had UCI Health pain experts rethinking their prescription practices.

“Historically, it wasn’t uncommon to see American physicians send patients home with a 30-day supply of opioid medication after surgery,” says Dr. Shalini Shah, director of Pain Services at UCI Health.

Proactive push to monitor opioids

That is changing, Shah says, as UCI Health physicians and surgeons have worked in the last several years to reduce the use of opioids – including hydrocodone, morphine, oxycodone and hydromorphone – while still controlling pain to ensure comfort during and after surgical procedures.

“When given a choice, we are seeing patients declining opioids more than in the past, and many do fine with anti-inflammatory or neuropathic medications, even after some types of surgery,” says Shah, who is also vice-chair and associate professor of Anesthesiology and Perioperative Care at UCI School of Medicine.

A recent study in the Journal of the American College of Surgeons found that many patients who underwent a pain management course were able to regulate pain after minor surgical procedures without opioids.

Offering alternatives

Even before these results were published, UCI Health physicians were aggressively monitoring the use of opioids, providing alternatives as appropriate for patients’ pain and carefully tracking the results.

In one study, UCI Health researchers examined more than 15,000 patients to monitor how many opioid pain medications were being prescribed after surgical procedures. They also instituted a pain management protocol during recovery to record patients’ pain levels and adjust medications accordingly.

Shah says the study, which she expects to publish soon, found a significant decrease in opioid prescriptions without any increase in pain scores using her team’s safe opioid prescribing tools. This initiative is now serving as a model for other health systems to emulate, she adds.

Researchers are also tracking the number of opioids used in and prescribed by the emergency department, as well as examining patterns of provider prescribing across the UCI Health system.

Patient education is key

For the last four years — and even more aggressively in the last two years — specialists at the UCI Health Center for Pain and Wellness in Irvine have made considerable efforts to educate patients about pain and pain-medication options.

Alternatives include anti-inflammatory drugs, nerve medications, muscle relaxants, nerve blocks and catheters. Complementary options such as acupuncture and mindful meditation are also useful.

“In our pain clinic, we see patients who are anxious about post-operative pain or are already on pain medications,” Shah explains. “We like to have a frank and open discussion about pain-management options prior to surgery.”

In addition to assigning a pain physician to the patient’s care team, pain center specialists discuss options for pain control on the day of surgery and the days immediately afterward.

“We talk about functional goals and explain how pain medications may affect their bodies,” she says. “I’m often surprised to hear patients who have been on painkillers for several years express gratitude because no one has ever taken the time to explain the risks and benefits to them.”

Common side effects of opioid medications

The most common side effects of opioid use include:

  • Dizziness
  • Nausea
  • Vomiting
  • Constipation
  • Slowed breathing, a particular problem for people with sleep apnea or other pulmonary issues

Physical dependence is also a very real concern. It takes only three to five days of opioid use to develop a dependency.

The synthetic opioid fentanyl is 50 to 100 times more potent than morphine, according to the National Institutes of Health (NIH). Nearly 60% of U.S. opioid deaths in 2017 were linked to fentanyl.  

Get answers to these questions

“Letting patients choose how they’d like to manage their pain is vitally important,” Shah says. “Patients should feel free to ask their doctor or a pain specialist questions about pain medications.”

She recommends that patients ask the following questions:

  • What are the harms, both short term (nausea and sedation) and long term?
  • What risk factors do I have that would make me more susceptible to an overdose?
  • Will I get addicted?
  • What are the signs of addiction?
  • What are the alternatives to opioids?

Sometimes opioids are needed

“There is a role for pain medications,” Shah says. “Surgery may be the most painful thing some people will ever experience. And patients may need more pain relief if they’re not meeting their functional goals after surgery.”

When UCI Health patients are prescribed opioid pain relievers, they’re usually sent home with the overdose antidote, naloxone. Pain specialists educate patients and their families to recognize the signs of an overdose in the rare instance that may occur.

To keep prescription opioids off the streets, UCI Health patients and their families are also educated about what to do with unused pills — such as safe storage, disposal or returning them to pharmacies, which will take them back.

But there are alternatives to opioids that allow patients to remain functional and have a smooth recovery, Shah says.

“We can deliver comfort and pain relief to patients after surgery without increasing the societal risk of addiction.”

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