Prescription opioids aren’t the first answer to managing pain

Orlando Health recently commissioned and published survey results on the public perception of opioids in the context of postoperative pain control. As a general surgeon focusing on minimally invasive and robotic techniques, I have increasingly advocated for multimodal opioid-minimizing pain control methods in surgical patients.

My practice has seen a gradual conversion from an opioid-centric pain control model to a multimodal pain-control model, utilizing opioids as a rescue medication for otherwise uncontrolled pain.

I am a vocal supporter of multimodal pain control, as well as the principles of Enhanced Recovery After Surgery (ERAS). ERAS protocols have been studied and implemented by the dedicated work of many clinicians over the past few decades, and they are becoming commonplace for many operations. Likewise, surgeons have been utilizing multimodal pain control methods to varying degrees for years.

However, I feel a strong obligation to advocate for a pain-treatment method that may be able to help provide compassionate pain control for our patients — while aiding in the transition from an opioid-centric pain model to a more measured multimodal model that allows for minimal use of opioids whenever possible.

In medicine, everything we do has an associated risk and benefit. Many times, there are numerous options that are all safe, medically appropriate treatments. But even safe treatments have unique risk profiles. The Food and Drug Administration has deemed that opioids are safe when used in medically indicated situations under the guidance of a qualified prescriber.

Many overdoses involve multiple substances, but government data estimates approximately 75% involve opioids. However, most experts agree the rise in overdose deaths is not being driven by legitimately prescribed opioids, but instead by the influx of counterfeit pills containing illicit fentanyl-like substances. While prescription opioids are reportedly involved in 40% of the overdose deaths, many of these involve diverted pills not used by the original patient or for the intended purpose.

Still, many people’s first exposure to an opioid is through medically indicated prescription opioids used in the routine treatment of pain. Unfortunately, this can lead to downstream consequences such as opioid dependence and, at times, opioid use disorder for a small portion of these patients. Even though these patients represent a very small subset of deaths in the current overdose crisis, would exposure to an opioid have been necessary at all if multimodal pain control had been fully utilized in management of their pain? There are those who can’t achieve effective pain control without the use of prescription opioids. Prescription opioids are not the enemy. Neither are the patients that need them. Furthermore, withholding their use in situations when they are needed to achieve compassionate pain control goes against the tenets of being a physician. Yet with billions of opioid pills left over every year, opportunities exist for a more thoughtful approach.

We have historically relied heavily upon opioids as the primary treatment of pain in a wide range of patients. With more effective use of non-opioid multimodal pain control, the number of patients requiring opioids to manage their pain could potentially be much lower.

It is unrealistic to think that all pain can be managed without an opioid given the currently available medications. Certainly, there will be situations that require the use of opioids to achieve compassionate pain control. Withholding prescription opioids without providing a viable alternative can lead to avoidable suffering. Chronic pain and palliative care patients are at risk of becoming collateral damage in the battle against the opioid epidemic.

In my practice a multimodal opioid minimizing approach has shown great potential. Again, it is my sincere hope that this discussion will not contribute to the stigmatization of medically indicated prescription opioids; a stigmatization that can have serious negative consequences on individuals that desperately need prescription opioids to achieve compassionate pain control. It is my opinion that systemic changes are needed to improve our methods of treating pain across our healthcare system and multimodal pain control is an underestimated ally in this fight.