Opioid Minimization Strategies for the Surgical Setting

The opioid epidemic continues to position itself as a mainstay in the media, demonstrating its vast and non-discriminatory impact. It’s likely this crisis has taken hold of the headlines in your state, city and potentially your hometown. While local and federal officials are working to develop solutions, doctors and surgeons are faced with navigating the careful balance between addressing a patient’s pain and avoiding overprescribing. In fact, a JAMA study found that more than two-thirds of patients have leftover opioids after surgery, resulting in a high number of pills available for possible diversion or misuse.[1]

 First, it’s important for us to focus on the operating room and the unique role that environment plays in the epidemic. Surgery has become an inadvertent gateway to opioid addiction with one-in-10 patients becoming addicted to or dependent on opioids following a surgical procedure.  The onus is on surgeons and healthcare professionals to seek out and adopt effective strategies to manage patients’ postsurgical pain while limiting their exposure to opioids. While opioids were once the gold standard for pain management, surgeons now have a variety of multimodal therapies and effective non-opioid options in their armamentarium enabling them to ease a patient’s concern regarding postsurgical pain.

 A multimodal approach to pain management allows surgeons to utilize two or more different methods of pain medications rather than relying solely on opioids. Deploying this type of treatment regimen has a broad range of benefits including improved postoperative pain scores, reduced need for opioids and a significant decrease in opioid-related adverse events.[2]A multimodal strategy is particularly common within innovative models such as enhanced recovery after surgery (ERAS) and the Perioperative Surgical Home (PSH). These models are evidence based, patient-centric pain management strategies that are put in place at hospitals and health care facilities to improve patient care, reduce the need for opioids and reduce health costs.[3][4]

 There are also a variety of non-opioid options available that effectively manage pain while limiting a patient’s exposure to opioids. These options include nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen, acetaminophen and long-acting local analgesics, like EXPAREL? (bupivacaine liposome injectable suspension), which is injected during a surgical procedure to help manage pain during the first few days when pain is usually at its peak. Many patients find that a combination of these non-opioid medications is sufficient to help manage pain after surgery, while easing fears of addiction or dependence. Beyond medication, patients and clinicians should discuss other options to support rehabilitation following surgery, such as physical therapy, acupuncture, chiropractic care and yoga. 

 The opioid epidemic is an issue that must be fought from all sides. As part of that fight, the National Institutes of Health (NIH) recently launched the HEAL (Helping to End Addiction Long-term) Initiative to accelerate scientific solutions to combat the opioid crisis. NIH has nearly doubled its funding towards addiction and misuse for this initiative. The NIH HEAL Initiative, is an organization wide effort, that will build on extensive, existing NIH research to develop and test treatment models and support research that can prevent and treat opioid misuse and addiction. 

 These are all effective steps to helping reduce patients’ exposure to opioids in the surgical setting. While PSH and ERAS protocols and NIH’s HEAL Initiative are strategies that are helping physicians reduce their use of opioids, I urge patients to be advocates for their own health and have an open dialogue with their doctor(s) about pain management options prior to surgery. Pain is different for everyone, and patients should feel empowered to discuss their options, including non-opioids, with their physicians to determine what should be utilized based on their specific needs. We still have a long road ahead to combat this epidemic, but surgeons and patients can make a difference and work together to reduce opioid prescribing by having honest and open conversations prior to surgery. 

[1]https://jamanetwork.com/journals/jamasurgery/article-abstract/2644905

[2]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4679301/

[3]https://erassociety.org/patients/

[3]https://acpm.health