Treating Surgical Pain With Reduced Opioids
Second in a series
Just a few years ago, people having surgery at Einstein Healthcare Network hospitals, and others around the country, often received opioids as their primary form of pain control in the hospital and after discharge.
“It was not uncommon for somebody to have surgery and go home with 40 to 60 pills of Percocet [oxycodone plus acetaminophen],” says Richard Fine, MD, Network Chair of Anesthesiology and Medical Director of the Operating Rooms at Einstein Medical Center Philadelphia.
For most patients, “80% of those were never used,” he says.
But throughout the country a small percentage of patients prescribed opioids (also called narcotics) after surgery became dependent, contributing to the opioid epidemic that exploded in the United States in the last 20 years.
Protocols now in place at Einstein take a vastly different approach. To ensure patient safety as well as adequate treatment of pain, Einstein guidelines implemented in the last few years minimize opioid use for surgical and other hospital patients.
Pain Managed Well With Less Medication
“I have found that their pain is being managed just as well as when I was using the longer-term narcotics,” says Eric Williams, MD, Associate Chair of Orthopedic Surgery.
According to the American College of Surgeons, nine out of 10 patients surveyed in research studies say that their pain is mild or gone within four days after surgery.
Dr. Williams was a surgical resident in the early 2000s when long-acting opioids such as Oxycontin, a brand of oxycodone, became available and were touted as safe and abuse-resistant. Around the same time, national organizations began to evaluate doctors and hospitals in part based on how well they treated pain.
“So at that time there really was more of a push to provide narcotic medications,” he says.
But later research showed that giving patients more pills could make addiction more likely.
“Our medication safety committee identified many issues that we were having in house, with the patients that were receiving either way too much of the opiates or were having complications because of their use,” says H. David Hares, MD, Vice Chair of the Department of Medicine at Einstein Medical Center Philadelphia.
Side effects of opioids may include constipation, nausea, dizziness, drowsiness, sweating and changes in heart rate.
Steps to Reduce Opioid Use
The initiatives to diminish opioid use at Einstein began with grassroots efforts by several doctors and evolved into the Opioid Network Committee, established in 2017. Since then, Einstein has taken several steps to reduce opioid use:
- Adding pain-management guidelines to the network’s electronic medical record system
- Using combinations of non-opioid drugs to reduce pain during and after surgery
- Using smaller amounts of opioids in the hospital and providing fewer pills upon discharge
- Educating doctors about the need to be more cautious in prescribing opioids
- Educating patients not to expect a pain-free recovery, and to understand the side effects of opioids
- Gathering data with the goal of identifying doctors who prescribe more opioids than others and determining why
The changes begin before surgery, Dr. Willams says. “I try to explain to the patient the importance of restricting narcotic requirements, that the longer you’re on narcotics, the greater chance your body gets addicted to them. I make great care to tell them that I’m not saying that’s something specific to them. It’s just what our evidence-based medicine shows.”
Minimally invasive surgical techniques have reduced pain after many types of surgeries, notes Radi Zaki, MD, a transplant surgeon and the Robert G. Somers, MD, Chair of the Department of Surgery at Einstein Healthcare Network.
Still, it’s important to let patients know to expect some pain, he says. “Then they do much better in terms of narcotic usage than a patient that doesn’t have understanding of what to expect,” he says.
“How you deal with the pain and how you manage the pain is important,” Dr. Zaki adds, “because a lot of people have anxiety and anxiety breeds more pain. So we say you will have pain, but it will get dramatically better quickly.”
Discharge Instructions Important
Most patients going home today after surgery get only a few days’ worth of opioid pills, Dr. Fine says.
Discharged patients receive instructions on how to treat their pain, primarily with larger-than-normal doses of medicines such as ibuprofen (Motrin) or acetaminophen (Tylenol), he notes. Some will also get muscle relaxants and medications for nerve-related pain.
They learn how to take these medications at staggered times during the day to provide continuous pain relief. “Then at night, if the pain is significant enough that it keeps them awake, they would take the opioid,” Dr. Fine says.
It appears that such an approach is effective. Recent research suggests that the vast majority of patients do fine after surgery when prescribed fewer opioid pills and are not more likely to request a refill.
Efforts to limit opioid use begin with the anesthesia given before, during and right after surgery.
“Before surgery, we give patients oral drugs like Tylenol, Celebrex, and gabapentin or Lyrica [pregabalin], which all act differently but all impact how pain is transmitted in the body,” Dr. Fine says. “And so by treating these different pathways, it enables us to use minimal amounts of narcotics in the operating room.”
For the surgery itself, Dr. Fine’s team often uses regional anesthesia, which blocks specific nerves to prevent transmission of pain for a period of time.
“So if someone’s having a total knee replacement, we can block the nerves that go to the leg so that when patients wake up, they’re pain free for up to 12 hours after surgery,” he says.
Another approach is to use an “intravenous cocktail” of drugs that work in different ways: ketamine, steroids and magnesium. “None of these approaches completely take away all the pain, but all mitigate the amount of opioids that are required,” Dr. Fine says.
For patients who are recovering from surgery, or in the hospital for other reasons, staff follow guidelines developed in 2018 for pain assessment and relief to minimize use of opioids, Dr. Hares says. For doctors, the guidelines are built into the electronic medical records system.
“With this approach, first we make a better diagnosis of what’s the origin of the pain. Then you have to address the patient’s expectations and explain what the medication may or may not do,” he says.
“So if somebody complains about pain that’s nine on a scale of 10, the medication should not make it zero, but it might make be three or four so the patient is functional, is able to sleep and to eat or drink or take a shower.”
The guidelines include “many nursing interventions like use of heating pads, use of cold, changing positioning, sometimes reassurance, and use of three or four other nonopioid medications around the clock as opposed to only when the pain is there.”
Doctors in some cases have needed to change their prescribing patterns, but they appreciate the institution’s clear guidance, Dr. Hares says.
“Now they know that the institution has their back in all their decisions of treating pain and at the same time preventing complications from the use of narcotics.”