Opi­oids should be last re­sort to man­age pain af­ter surgery

Orlando Sentinel - - OPINION - By Dr. Randy Schwartzbe­rg

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.

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