Surgeons are finding that they can prescribe fewer pain-killing opioids after surgical procedures and still achieve effective pain relief. "In the months after new guidelines went into place [in Michigan], the number of opioid pills being prescribed to surgery patients fell by one-third overall, yet there was no change in patients' satisfaction with their pain control." The findings were published in the August 15 issue of the New England Journal of Medicine. "This isn't just about reducing opioid use," said lead researcher Dr. Jocelyn Vu. "It's also about giving patients the best care for their pain.”
Before the guidelines were put into place, Michigan doctors prescribed an average of 26 opioid pills post-surgery. After the guidelines, that number fell to 18. Although patients were given fewer opioid pills, pain scores in the 6,000 patients surveyed showed no change when compared to pre-survey data. "This shows how a relatively simple intervention, at the state level, can make a difference," said Dr. Allen Gottschalk, a professor of anesthesiology at Johns Hopkins University.
Developed by the Michigan Opioid Prescribing Engagement Network (aka Michigan-OPEN, the guidelines specify how many pills should be prescribed for patients undergoing certain procedures: From 5 to 10 pills for appendectomy, hernia surgery, prostate removal, or breast tumor removal. But zero opioids for removal of wisdom teeth. For surgeries likely to cause more pain, such as joint replacement or a Cesarean delivery, from 20 to 50 opioid pills may be prescribed.
A related study showed that older patients undergoing cardiac or lung surgeries are more likely to become opioid dependent, when compared to other surgery patients. Led by Alexander Brescia, M.D., this study analyzed data from approximately 25,000 Medicare enrollees, average age 71. Nearly 13% of this population segment developed new persistent opioid use after undergoing heart or lung surgery. The researchers concluded that the risk of becoming opioid dependent is "strongly associated with the number of opioid pills prescribed after surgery" (per medpagetoday.com).
Cutting back on the number of opioid pills based on the surgical procedure performed has other benefits as well. It helps patients avoid taking more pills than necessary and prevents them from ending up with leftover pills that might be used (or abused) by someone else.
Of course, experiences or expectations regarding pain relief after surgery vary from patient to patient. Prior to surgery, whenever possible, doctors and patients need to talk about pain control options other than opioids, including alternatives such as NSAIDS. In fact, post-surgical patients may discover that they need less pain medication than they had expected.
Although the CDC has published recommendations on the use of opioids for chronic pain, there are no national guidelines for opioid use for post-surgery pain. Michigan has demonstrated that appropriate guidelines can be developed and implemented effectively at the state level.
Ken Teufel, M.D.