Opioids should be last resort to manage pain after surgery
The opioid crisis continues to plague the nation, and Florida is no exception. In fact, a recent report from the Journal of the American Medical Association (JAMA) revealed that Florida is one of the two states hit hardest by the epidemic. Despite the unwanted side effects and risks associated with opioids, these medications are often still overprescribed in the surgical setting.
As an orthopedic surgeon practicing in Orlando, I’ve made it my priority to minimize the risks of opioids by using an opioid-sparing multimodal approach to manage patients’ pain before, during and after surgery.
In addition to determining who would benefit from surgery and performing the surgery with great deft, the role of a surgeon is to also direct their patients’ postoperative care to return them to their prior state of health. This includes postoperative pain management. Opioid medications have been relied on for years for such management and have been the focus of a portion of the opioid epidemic.
In order to combat this, I have been utilizing a variety of non-opioid options to minimize or even eliminate the use of the opioid medications. This so-called multimodal approach to pain management has led to quicker recovery times, more satisfied patients and a greatly reduced exposure to opioids.
My multimodal approach to pain management includes the routine use of nonsteroidal anti-inflammatory medications (NSAIDs) and acetaminophen. Cryotherapy is also encouraged. This involves regimens of ice or cold therapy machines that aid in swelling and postoperative pain. For more involved surgical procedures, patients receive regional nerve blocks from anesthesiologists that can provide substantial pain relief for up to a day after surgery.
A more recent innovation that my partners and I have used at Orlando Orthopaedic
Outpatient Surgery Center is the use of a FDA-approved long acting local anesthetic. My partners and I have studied the efficacy of this nerve block by having shoulder surgery patients keep postoperative pain diaries and record the number of opioid pills taken in the five days after surgery.
The pain control and very minimal opioid use due to this longer acting block and our multimodal approach has been remarkable. There is a significant portion of our patient population who do not take any opioids after surgery.
Several reasons exist for a lack of widespread acceptance of these successful pain management techniques. One reason includes lack of awareness and education for patients and even for some surgeons. I believe that it is critical for surgeons to have conversations with their patients regarding diverse pain management methods that minimize or eliminate opioid exposure.
Another barrier to use opioid alternatives in the surgical setting involves the lack of insurance reimbursement for some of these items. Medicare does not currently provide adequate reimbursement to hospital outpatient departments for such useful non-opioid pain control options.
Although legislators across the country have passed admirable legislation to help curb the opioid epidemic, more work should be done to cultivate and provide affordable access to non-opioid options. I have reached out to local policy makers to try to make these thoughts known.
As a society, we are making strides in this country to attempt to curb the opioid crisis. As surgeons, it is imperative that we optimize our role. The use of a multimodal approach for postoperative pain management should be standard.
Different patients may need different approaches. There is not a one size fits all approach. Surgeons can help prevent some opioid addictions before they start and provide excellent postoperative pain management at the same time.
The use of a multimodal approach for postoperative pain management should be standard.