Managing pain with fewer or no opioids

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This was a typical scenario circa five years ago: You went to the hospital for an elective surgery—say a hernia repair, hip replacement, or carpal-tunnel surgery. Back then, your doctor and hospital were evaluated on how well they treated your pain. And, since the fastest way to eliminate pain was with a new generation of supposedly safer narcotics, they sent you home with an opioid prescription. 

Ralph Pennino

Maybe you took those pills and developed a dependence; some 6 percent to 10 percent of surgical patients become new, persistent opioid users—a significant surgical complication.

Or maybe you took a few pills and shelved the rest in your medicine cabinet, next to another family member’s pills from a different surgery. More than 70 percent of prescribed opioids go unused. They often sit in drawers and medicine cabinets, giving family members, visitors—and in one known instance the babysitter—easy access to a free pharmacy of controlled substances.

And so the opioid crisis grew.        

A study by the Center for Public Initiatives at Rochester Institute of Technology found that there were 1,133 reported overdoses in Monroe County roughly two years ago. Overdoses involving opioids killed more than 47,000 people in the United States in 2017, according to the Centers for Disease Control and Prevention. Some of those deaths came from illegal street drugs. But 36 percent of them involved prescription opioids.

Today, a more enlightened approach to pain management must become part of the solution. 

Multi-modal pain management

Opioids still play a role—albeit a smaller one—in pain management for major surgeries or trauma. But of approximately 60,000 surgeries and procedures performed at Rochester Regional Health annually, more than 90 percent are elective and routine—such as hernia repairs, joint arthroscopy, and hand surgeries. You don’t need to go home with a fistful of opioids for those. There are much better and safer ways to manage pain.  

Here’s how: 

Before surgery: It’s essential to discuss expectations about recovery and pain management. Discomfort is a normal part of healing, but it shouldn’t be overwhelming or incapacitating. I tell patients there will be discomfort, and we’ll get them through it.   

Surgical pain is typically worse the day after surgery and after that diminishes quickly. To minimize post-surgical pain, non-steroidal drugs and non-narcotic medications can be used to reduce inflammation and nerve pain. 

During surgery: A nerve block, a local anesthetic catheter, or a regional block can help patients wake up with less or no pain. The relief lasts up to 24 hours. Between the preoperative and intraoperative treatments, many patients get through that most challenging first day with little pain, and often no opioids at all.     

After surgery: Postoperatively, patients can go home with safe and highly effective pain management tools and strategies. Much of the pain from knee surgery, for example, comes from inflammation. Ice reduces inflammation and speeds recovery. Ice-therapy machines used in hospitals can also be rented or purchased for home use. Or, there is always the simple ice pack from the freezer, wrapped in cloth. 

Other non-drug techniques such as mindful breathing and relaxation, listening to music, reading, or calling a friend can be remarkably effective. 

When medication is needed, alternating acetaminophen (Tylenol) and ibuprofen (Motrin or Advil) around the clock while awake often is enough.   

The diminished role of opioids

But even with all of these first-line tools, opioids including Oxycodone or Tramadol sometimes still are needed. Instead of prescribing large quantities of these, providers can apply evidence-based guidelines from industry organizations including the Michigan Opioid Prescribing Engagement Network (Michigan OPEN) and the American College of Surgeons. 

Instead of going home with 100 or more pills after total knee replacement surgery, for example, a patient might be prescribed 50. We consult a list of recommended number of opioid pills to prescribe for each type of surgery, from five tablets for a tonsillectomy to 50 tablets for a total knee replacement. 

Doctors at first worried this would lead to a deluge of refill requests. It didn’t. Doctors worried it would reduce their patient-satisfaction ratings. It doesn’t. Industry research verifies this. 

Modern pain management is integrative  

Evidence-based guidelines do not replace clinical judgment. Each patient is unique and has unique treatment needs. Meeting them takes coordination across the entire care team including surgeons, physicians, advanced practice providers, anesthesiologists, bedside nurses, and pharmacists. Modern pain management is an integrative discipline, not a quick fix.

But the results are significant. Since 2015, for example, Rochester Regional Health emergency departments have reduced opioid prescriptions by 90 percent. People coming in with sprains, bruises, cuts, and coughs no longer routinely leave with opioid prescriptions. For patients with broken bones and other conditions requiring opiates, RRH emergency departments now prescribe morphine immediate release, which has less of the euphoric properties of oxycodone and hydrocodone. RRH also is driving down opioid prescriptions in primary care and post-operative care.

Many years ago, when I was a surgical resident, patients woke up from surgery in a lot of pain. That doesn’t have to be so anymore. The expectation, however, isn’t no pain. The expectation is discomfort managed so you can eat, move, sleep, breathe deeply—and heal.  

Ralph Pennino M.D. is senior vice president of the specialty medicine and surgery group at Rochester Regional Health. Selma Mujezinovic, DNP, FNP-BC, RRH vice president, advanced practice providers, contributed to this article. 

3 thoughts on “Managing pain with fewer or no opioids

  1. Sorry Dr. Pennino , I’m not buying it . The opioid crisis was not about pain management but about “legal ” drug pushers making a ton of money . The evidence is overwhelming . The latest info is 1oo billion pills in less than a decade , thru only legal prescriptions , according to the Washington Post . I have had arthroscopic surgery on both knees and when bone is shaved and cartilage cut the pain was mind-numbing for four days . After the extensive bandages are removed due to the fear of infection , I could manage the next few days with ice packs . Ice was not effective thru the bandaging . Even after four days I spent a day under a heavy blanket with nausea and cold sweats from withdrawal , uncomfortable but necessary .
    In 1983 I destroyed an anterior cruciate knee ligament . It was at a time of ” just say no ” and the height of the War on Drugs . Increased scrutiny of Doctor’s prescription records caused many to let their patients suffer and I did . Needless to say I never would return to that physician . We don’t let animals suffer like that . When someone has a procedure like arthroscopic knee surgery and still needs opioids after seven to ten days , they either have an unsuccessful or a botched surgery . In such cases I have seen people renew opioid prescriptions for weeks , months , and even years that were not warranted . This crisis is mainly about the greed of pharmaceutical companies , hospitals , and some doctors , not pain management . Don’t throw all patients under the Bus .

    • I am sorry you had that experience with arthroscopic surgery. That is certainly not the typical experience. Every surgery is different. But this is the type of suffering we strive to prevent through multi-modal pain management rooted in evidence-based best practices. It’s not about “just saying no” to opioids. It’s about using non-narcotic means , along with other modalities we now have available to reduce inflammation and nerve pain. In this context, opioids still play a role and are needed but in a far diminished role.

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