San Antonio Express-News (Sunday)
Houston doctors work to eliminate opioids
When it came to surgery, this wasn’t George Sabin’s first rodeo.
He landed in the hospital at age 13 after a motorcycle accident. Five years later, another wreck brought him back to the emergency room and ultimately resulted in the loss of his arm.
Sabin’s more recent surgeries have included repairing a torn rotator cuff, injured knee and two herniated disks.
With all of his hospital experiences, Sabin now has his recovery routine down pat.
For Sabin, that means skipping the opioids generally prescribed as painkillers. Instead, he prefers extra-strength doses of aspirin, Tylenol or ibuprofen.
“I’m always driving somewhere, trying to do something,” he said. “I can’t have a diminished ability to get done what I want to do. I try to avoid opioids as much as possible. They just slow me down.”
The opioid epidemic, which claims the lives of an estimated 130 people a day and was declared a public health emergency by the U.S. Department of Health and Human Services in 2017, only reinforced Sabin’s reluctance to take the painkillers.
Fortunately, after his recent colon cancer diagnosis, he found a physician on the same page:
Atif Iqbal, associate professor and chief of colorectal surgery at Baylor College of Medicine.
After working to reduce opioid use in his treatments for the past 10 years, the doctor has completely eliminated using the drugs.
“He tells you what your
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options are, instead of telling you what to do,” Sabin said. “And I was trying to avoid painkillers at all costs.”
Billy Moreton, of Huntsville, also opted to forego opioids when he headed to Houston after a knee replacement surgery had gone bad. Moreton never healed fully from an earlier operation in 2018, and his knee became infected.
“It’s been a nightmare,” said Moreton, who has stuck to a rotation of Tylenol, Motrin and Advil to navigate the pain over the past two years.
Like Sabin, he also discovered a surgeon who allowed him to avoid opioids when repairing his knee: Dr. Mohamad Halawi, Baylor College of Medicine associate professor of orthopedic, hip and knee replacement surgery.
“Halawi doesn’t even prescribe opioids, and I didn’t ask for them,” Moreton said. “So many people get hooked on
opioids. I don’t like to take them unless I absolutely have to.”
In the late 1990s, health care providers began prescribing opioids at increasingly high rates, after assurances from drug companies that the product was not addictive.
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But it was — very much so. According to the U.S. Department of Health and Human Services, 10.3 million people misused prescription opioids in 2018. Now, as more light is shed on the crisis caused by their use, more patients these days are asking for alternatives to opioids.
“More and more patients are on board with not using narcotics,” Iqbal said.
Still, both Iqbal and Halawi believe it’s up to the medical community to lead the way when it comes to opioid-free treatment.
And the extra effort is well worth it, according to the surgeons.
“It’s definitely easier to do it on this end than to have to rehab the patients,” Iqbal said.
Halawi prefers eliminating the prescriptions in the first place — and he hopes that other surgeons will catch on to the trend.
“It’s a leap of faith for the surgeon,” he said. “It takes courage to break with old habits, but I really think opioid-free surgery is the way of the future.”
Moving off narcotics
For the past year, Halawi performed completely opioid-free surgeries, and before that, he wanted to minimize the use of narcotics in his treatments.
“As a physician, I cannot think of a class of prescriptions with a higher capacity for addiction and overdose — or a greater number of side effects,” he said. “I’ve seen firsthand how much those side effects have hindered recovery.”
In Halawi’s mind, opioids were causing more problems than they were solving.
“And one of the big principles of medicine is do no harm,” he said.
When he started practicing, he assumed that dealing with the side effects of opioids was par for the course.
“I literally went by the book,” he said. “This was the way we were trained, prescribing opioids to each patient after surgery. We were trying to solve a problem. In the process of solving the problem, though, we actually created other problems.”
His patients consistently complained about common side effects, like constipation, nausea, drowsiness and even difficulty breathing.
“It was all completely avoidable,” Halawi said. “I realized that I was losing sight of the actual recovery and focusing on unnecessary issues.”
Iqbal had a similar realization while practicing in Florida, where the opioid epidemic was raging.
“Half the deaths involved prescription opioids,” he said. More than a third of those prescriptions were traced back to the surgical setting. Often, patients first took the pills while recovering from an operation.
“Surgeons are creatures of habit,” Iqbal said. “We do something the same way every time, just because it works. And we were taught that narcotics were the first and only way to deal with postoperation pain.”
That’s simply not the case, he discovered.
“Unfortunately, that realization is not mainstream yet, and physicians have to be a part of ending this epidemic,” he said.
New approach to pain
Before moving to Houston, Iqbal was surprised to find that patients who did not receive opioids saw no difference in pain levels, compared with those who did.
“Their pain scores were the same. That’s a big deal,” he said.
“I eventually realized that pain is actually determined by a combination of objective and subjective factors,” Iqbal said.
“While patients did objectively feel pain after surgery, they also had certain preoperation perceptions and expectations.”
Those fears and anxieties about surgery itself drove up the level of complaints for patients.
“Keeping them updated every step of the way, allaying anxiety and fear, treating a patient with dignity and respect, goes a long way,” Iqbal said.
Then, before a surgery, patients can begin taking Tylenol, Motrin or gabapentin, a nerve pain medication.
During operations, surgeons follow a multipronged approach, using local analgesics, nerve blocks and spinal anesthesia instead of general anesthesia.
After the procedure, the patients return to Tylenol, Motrin and gabapentin.
“If all else fails, narcotics may be needed, but even then we can start with less,” Iqbal said. “Compare this to how we were taught, that every single patient gets an IV pump full of narcotics. It’s a change in how we’re doing things. Even more important, it’s a change in how we’re thinking.”
It requires a cultural shift, said Halawi. In the past, he said, pain treatment was reactionary. Doctors would evaluate a patient’s pain level and then turn to opioid doses to provide relief.
“Then, we would give them more and more
opioids until the pain went away,” Halawi said. “Now, we can start ahead of the pain and continue to stay ahead. The idea of all the interventions is to stop the pain in its tracks.”
‘Change in mindset’
Gone are the days of telling patients that there will be zero pain after a surgery, Iqbal said.
A more realistic expectation is that discomfort will be minimal.
“That leads to a change in the mindset of patients, and they’re actually happier,” Iqbal said. In the past, patients would often feel drugged and stay in bed, which could result in blood clots and pneumonia.
“That’s a compounding problem,” Iqbal said.
Without using opioids, Halawi was actually able to reduce the amount of time patients spend in the hospital and speed up recovery.
“It’s effective, more efficient and the patient’s experience is a lot better,” he said. “A patient doesn’t have to go through the side effects, and they can recover very quickly.”
Halawi wants patients to know they have options — and that eliminating opioids does not mean added pain.
“People have a choice,” he said
In the pandemic
During the coronavirus pandemic, Halawi said, the need for efficient procedures has become increasingly evident.
“In a COVID era, we can leave hospital beds for those patients who really need them,” he said. “You can do major, complex cases and still recover from home. As physicians, we can drive down the cost and provide better care.”
Delivering better value is central to health care reform, he said, noting that rethinking the business of medicine has been a side effect of the pandemic.
“Staying in the hospital longer is bad,” Iqbal said. “The more hospitals are full, the more elective surgeries are canceled, and that can keep patients from getting the care they need.”
When the pandemic started, nonessential operations completely ceased, including the knee and hip replacements Halawi performs. Sometimes, that left a patient living in pain for months.
Instead of being at the mercy of disease surges, Halawi suggests developing ways to offer sameday surgeries, where patients can recover at home, reducing stress on hospitals and medical resources.
“We can continue offering help to patients and, at the same time, reserve vital resources for the patients who need them,” Halawi said.
“We’re stuck with COVID-19 for some time. The way to do business has to be more nimble. We can use this as a learning experience.”