A new review suggests that non-opioid analgesic therapies are becoming more important in improving recovery and satisfaction among elderly surgery patients in ambulatory settings.1 Surgery centers increasingly are seeking alternatives to opioids for pain relief.
Reasons for this shift — albeit a slow one — away from opiates is twofold.
“First, in this country we’re dealing with an opioid/narcotic epidemic,” says Paul White, PhD, MD, a researcher and consultant with the department of anesthesiology at Cedars-Sinai Medical Center in Los Angeles.
Secondly, elderly patients demonstrate a higher incidence of constipation and bladder dysfunction as part of the aging process, White says. “Additional opioids are administered postoperatively to the elderly, they’re at very high risk of constipation and, in some cases, ileus may develop.”
The traditional practice of prescribing opioid-containing oral pain medication after surgery must be re-assessed. White offers this example: “When I had a hernia repair under local anesthesia, I was given a prescription for 40 Lortab pills when I was discharged home from the surgicenter,” he says, adding that prescribing excessive quantities of opioid-containing pills can be a problem as the unused pills can be diverted or end up in someone’s medicine cabinet where a child could find them.
“Another problem is that people start taking these highly addicting drugs after surgery and continue to take them, thereby becoming addicted to the opioid medication,” he explains. “Also, the leftover pain pills are sold on the black market for $50 to $100 per pill.”
Clinical research has shown that there are many effective pain-relieving alternatives to opiates for managing post-surgical pain. Non-opioid analgesic therapies have been proven to be highly effective, including infiltration of the incision sites with local anesthetics, as well as single-shot peripheral nerve blocks with local anesthetics. Rapid and short-acting local anesthetics for spinal/epidural anesthesia also can be beneficial for some day-case surgery procedures in older patients. Parenteral ketorolac is an extremely valuable adjunct to the local anesthetics during the perioperative period. IV acetaminophen also can be a useful adjuvant.1
“By using a combination of non-opioids such as local anesthetics, and non-steroidal anti-inflammatory drugs [NSAIDs] like ketorolac, ibuprofen, naproxen, diclofenac, and COX 2 inhibitors like celecoxib, as well as a variety of other non-opioid analgesics — acetaminophen, ketamine, clonidine, gabapentin — you can minimize the need for opioid medication,” White says. “Opioids should be used only as a rescue drug if pain is not adequately controlled by non-opioids, and the need for long-term opioid use could be eventually eliminated.”
As alien as this viewpoint might seem to many surgeons in the United States, there are examples of how this approach can work. White recently traveled to Chile to speak to doctors about using non-opioid analgesics for treating post-surgical pain. He found that they do not routinely prescribe oral opioid-containing medications after surgery. Instead, they rely on local anesthesia and NSAIDs, including some generic analgesic medications that are used in Chile and Europe, but are not approved in the United States.
“We’ve done research that has shown that the perioperative use of NSAIDs and COX-2 inhibitors significantly reduces the need for post-discharge opioids and will facilitate the recovery process while also reducing opioid-related side effects,” White says.
Another reason why surgeons should think twice before prescribing opiates to elderly patients is because of a little-understood side effect of opioid-induced hallucination, White says.
This important issue was addressed recently in one of the major anesthesia and analgesia journals, he adds.
“In my own case, my mother had heart surgery about 25 years ago and started seeing devils that she thought were trying to kill her,” White says.
White also has heard from a friend who recently underwent cardiac surgery that three elderly men in the step-down recovery unit, including White’s friend, experienced disturbing hallucinations.
More commonly, use of large doses of opioids in the elderly can lead to excessive sedation and clinically significant cardiovascular and respiratory depression, he notes.
“It’s well-known that perioperative use of opioids produces sedation and has adverse effects on bladder and bowel function and sedation; however, opioid-induced hallucinations and hyperalgesia have only recently been emphasized,” White says. “The point is that the elderly are at greater risk of adverse side effects of opioid-containing medications. Opioids can affect almost every major organ system in the body.”
- Cao X, Elvir-Lazo OL, White PF, et al. An update on pain management for elderly patients undergoing ambulatory surgery. Curr Opin Anaesthesiol 2016. Epub ahead of print.