EXECUTIVE SUMMARY

Surgeons nationwide are developing opioid-sparing methods to help surgical patients avoid narcotic misuse and abuse.

  • The U.S. opioid epidemic has resulted in more than half a million deaths over the past two decades, and healthcare providers have contributed to the problem.
  • A recent American Academy of Orthopaedic Surgeons meeting featured several studies that revealed success with reducing opioid prescriptions and preoperative use of opiates in surgical populations.
  • Surgery centers need to prevent the perioperative encounter from becoming a starting point for patients’ opioid dependence.

As the nation’s opioid epidemic rages on, surgeons are among those leading the way toward finding opioid-sparing solutions.

Healthcare providers contributed to the epidemic, writing opioid prescriptions at a rate that increased by 3% each year between 2006 and 2010 before slowly decreasing. Since then, the rate has settled in at 58.5 prescriptions per 100 persons (as of 2017).1

The opioid epidemic was fueled, in part, by the healthcare industry’s earlier evolution regarding pain management. Patients began to expect a pain-free experience after surgery. Doctors referred to pain assessment as the fifth vital sign, says Kirk A. Campbell, MD, assistant professor in the department of orthopedic surgery at NYU Langone Health.

“Patients and providers were more likely to mention pain, and patients expected zero pain from procedures,” Campbell says. “However, you have to balance the risks and benefits of using very powerful medications in terms of narcotics. There’s no denying the reports that more patients and family members are dying from these medications.”

In a national database study of American adults who filed insurance claims after surgical procedures between 2008 and 2014, investigators found that 5,276 surgery opioid-naïve patients before surgery developed persistent opioid use up to six months after surgery. While surgeons had prescribed opioids to surgical patients for the first three months after surgery, primary care doctors continued writing the prescriptions.2

“In today’s environment, with widespread appreciation of how common and dangerous prescription opioid abuse is, it is critical to avoid allowing the perioperative encounter to become a starting point for a patient’s opioid dependence,” says David Liska, MD, a colorectal surgeon at the Cleveland Clinic. Reducing opioid uses in perioperative care also benefits patients medically, he adds.

By 2016, nearly one in five adults and youths in the United States reported drug use or misuse, including misuse of prescription painkillers. In that same year, there were more than 63,000 drug overdose deaths, two-thirds of which involved opioids.1 Health systems, physicians, and surgery centers are starting to change their opioid-prescribing practices, acknowledging the dangers and drawbacks of overprescribing narcotics for pain.

“Even before the opioid epidemic started making national headlines, minimizing opioids in perioperative care was recognized to be an important factor in accelerating patients’ recovery,” Liska says. “Opioids have well-established short- and long-term side effects that can impede a person’s recovery after surgery. These include oversedation and dizziness, which interfere with patients’ ambulation and physical therapy.”

Another important side effect that is especially notable in GI surgery is the opioid-induced development of postoperative ileus or constipation, Liska says. The problem with surgeons continuing to prescribe opioids as usual is that patients really do not use all the pills. The leftovers can be swiped by someone who is abusing the drug.

“In trying to curb the opioid epidemic, when patients came into our office, we asked how many prescribed medications they were using. We found the vast majority of patients were not using their prescribed medications,” Campbell reports. Patients kept leftover pills in medicine cabinets, which can lead to someone else using the medication, he notes.

A current theme in opioid-sparing involves helping patients reset their expectations about pain. Patients might expect to receive enough opioids to last a month, but surgeons need to help patients understand that this is not in their best interest.

Various research presented at the American Academy of Orthopaedic Surgeons 2019 Annual Meeting, held March 12-16, 2019, in Las Vegas, revealed success with pain treatment that did not rely heavily on opioids. The authors of a study of 80 orthopedic surgery patients at NYU Langone found that when patients are prescribed 600 mg of ibuprofen along with a 10-pill rescue prescription of oxycodone, they consume significantly fewer opioids than if they only had a prescription of 30 tabs of oxycodone 5 mg, Campbell says. One week after surgery, patients who were given prescriptions for ibuprofen and opioids for breakthrough pain would only use two pills of Percocet on average. This contrasted with patients who received only the opioid prescription. Those patients used 4.5 tablets of Percocet on average, Campbell reports.

“We also found that 53% of patients who got just Percocet chose not to use the Percocet and used over-the-counter anti-inflammatories or Tylenol,” Campbell says. “This one study has opened our eyes. We’re definitely overprescribing.” Researchers also found no significant difference in pain control and patient satisfaction between patients on the opioid-sparing protocol and patients who received only opioids.3

Surgeons have been hesitant to adopt opioid-sparing programs, and patients have been hesitant in complying with them. Thus, education is necessary on both sides of the scalpel, says Roy I. Davidovitch, MD, Julia Koch associate professor of orthopedic surgery at the NYU School of Medicine and director of the outpatient joint replacement program and The New York Hip Institute at OrthoManhattan.

“As orthopedic surgeons, we have a social responsibility to decrease the footprint of opiates in our daily clinical practice,” Davidovitch says. “Obviously, only a small percentage of our patients will become dependent on opiates overall, but the vast majority of heroin addicts started out with prescription opiates. It’s definitely necessary for that cycle to be broken somewhere.”

Surgeons should start the process of changing the opioid-prescribing paradigm.

“It’s the kind of thing where you climb a mountain and think it’s the only pathway to get to the top. Then, you look down, and people are figuring out other types of approaches to this,” Davidovitch says.

Davidovitch and colleagues now send patients home with an opioid prescription that includes no refills. “We wanted to track how much opiates the patients were taking,” Davidovitch says.

“If you send patients home with refills, you don’t know how much of the drug they are taking.” With the prescribing change, patients demonstrated improved movement and reported fewer adverse effects, Davidovitch adds.

A recent consensus statement published by the American Society for Enhanced Recovery and Perioperative Quality Initiative addresses opioid-sparing and opioid-free anesthesia. The statement’s goal is to minimize opioid-related complications by providing risk stratification, optimal perioperative treatment approaches, and optimal discharge and continuity of care management practices for patients receiving opioids preoperatively. (Editor’s Note: Learn more about the consensus statement at: http://bit.ly/2IHpv7V.)

“This was a consensus conference where European and American societies got together to write consensus statements on opioid use,” says David A. Edwards, PhD, MD, assistant professor at Vanderbilt University Medical Center. The focus of the paper is a consensus that is based on the quality of research about opioid use for surgical patients.

“Not a lot of literature talks about the risks of patients who are already on opioids or who live with chronic pain,” Edwards says. “We’re in the middle of an opioid crisis, and we’re taking all of these patients into surgery, and we have little to go on.”

Some healthcare organizations are taking the lead on developing opioid-reducing programs. For example, the Cleveland Clinic’s department of colorectal surgery offers an enhanced recovery pathway in which they routinely employ multiple tactics to minimize perioperative opioid use, Liska says. Also, patients in the preoperative holding area receive a multimodal cocktail of non-opioid pain medications aimed to pre-emptively treat the surgical pain, he adds.

“During surgery, our anesthesiologists continue using different non-opioid medications to minimize the need for opioids,” Liska explains. “Our surgeons use minimally invasive surgery techniques, using small incisions, which have been shown to reduce postoperative pain.”

Surgeons or anesthesiologists also administer a transversus abdominis plane block that anesthetizes the abdominal wall and reduces pain. Sometimes, an epidural is placed before surgery, which can be effective in reducing postoperative pain, Liska adds.

“Following surgery, we continue administering scheduled non-opioid medications, including acetaminophen, NSAIDs, and gabapentin. Opioids are only being used for breakthrough pain,” he says. “At the time of discharge, many of our patients don’t require any opioids to go home with and will continue using non-opioid medications to manage any residual pain.”

REFERENCES

  1. Centers for Disease Control and Prevention. 2018 Annual Surveillance Report of Drug-Related Risks and Outcomes — United States. Published Aug. 31, 2018. Available at: http://bit.ly/2GzCtkL. Accessed April 29, 2019.
  2. Klueh MP, Hu HM, Howard RA, et al. Transitions of care for postoperative opioid prescribing in previously opioid-naïve patients in the USA: A retrospective review. J Gen Intern Med 2018;33:1685-1691.
  3. Pham H, Pickell M, Yagnatovsky M, et al. The utility of oral nonsteroidal anti-inflammatory drugs compared with standard opioids following arthroscopic meniscectomy: A prospective observational study. Arthroscopy 2019;35:864-870.e1.