Surgery and Opioids: Changing the Perioperative Patient Experience and Expectation

HARRISBURG, Pa. - Should patients expect their doctor to write an opioid prescription when recovering from surgery?

In recent years, they have. Studies show that not only are patients going home with a prescription for drugs like oxycodone, but they're also filling those prescriptions at a high rate.

A report published in the Journal of the American Medical Association (JAMA) in March 2016 found that out of 14 million patients studied who underwent certain operations considered low-risk, 80 percent filled a prescription within seven days for any opioid.  The overwhelming majority – 86 percent – of these prescriptions were for hydrocodone/acetaminophen or oxycodone/acetaminophen.

Another study also published in JAMA during March 2016 involved more than 2.7 million Medicaid subscribers who had a tooth removed. That study found 42 percent filled a prescription for an opioid within seven days.

"Pretty clearly, opioids after surgery have become a routine of postoperative pain management," says Scott Shapiro, MD, president of the Pennsylvania Medical Society.  "However, with worries rising about the addictive nature of certain pain relievers and pressure building to address an overreliance on such medications, the days of this type of prescribing are numbered."

Dr. Shapiro says as prescribing practices change, patient expectations and thus patient satisfaction when recovering from surgery will need to be nurtured as other options are tried.

Opioids Explode Onto The Scene

Although Americans make up only 4.6 percent of the world population, they consume 80 percent of global opioid supply.  That figure increases to 99 percent when looking at hydrocodone.

From 1997 to 2007, retail sales of commonly used opioid medications jumped from 50.7 million grams to 126.5 million grams.

With such increase, it should come as no surprise that the number of people who admitted to abusing painkillers also increased. One study suggests that between 1992 and 2003, there was a 90 percent surge in abuse.

"Emergency departments often see the end-result of opioid abuse," says Merle Carter, MD, FACEP, president of the Pennsylvania College of Emergency Physicians who practices medicine in Philadelphia. "Certainly over my career, I've seen too many individuals end up in my emergency rooms who have overdosed."

In mid-February 2016, Modern Healthcare took a closer look at the root of the country's opioid abuse problem and traced it back to 1996 when Purdue Pharma began promoting a new drug to fight pain – OxyContin. Early on, the medication was billed as being safe because it would slowly release narcotic ingredients, making it unlikely to become addictive.

"We were told that this new drug would be the answer to many issues related to pain, particularly since a year earlier pain became the fifth vital sign and the American Pain Society recommended it be added to the indicators that assess overall health," says Bradley Levin, MD, FACC, FACS, FASAM, DABAM, CMRO of York County Medical Society who is also a member of the York County Heroin Task Force. According to Dr. Levin, there was even a time when physicians would be penalized for not prescribing opioids.

Nearly 10 years later in 2007 Purdue would plead guilty in federal court to criminal charges that they misled regulators, doctors, and patients about the drug's risk of addiction as well as its potential to be abused.

"We know better today, but the beast was unleashed and as addictions grew so did doctor shopping and other illegal activities," says Dr. Levin. "Those seeking pills got really good at finding what they wanted and in some cases pushed the drug out onto the street."

Post-surgery: If not opioids, what?

While opioids have been the primary treatment for pain while recovering from surgery, side effects and adverse reactions are possible, and they're being addressed by both physicians and patients.

"Opioids can cause nausea, confusion, vomiting, constipation, and respiratory depression as well as the risk of abuse," says Patrick Smith, MD, vice president of the Pennsylvania Orthopaedic Society (POS).  "Orthopaedic surgeons are implementing multimodal protocols in the pre-surgery period as a means to reduce patient pain, shorten the recovery period and avoid opioid use."

According to Dr. Smith, who is chair of the POS Opioid Task Force, orthopaedic surgeons begin post-operative pain reduction modalities at least one week prior to surgery.  Total knee replacement is a prime example.  In the past, this procedure required hospitalization for almost a week in addition to several weeks of post-surgery opioid pain medication. Today's multimodal approach allows patients to take fewer narcotics and spend only a day or two in a facility. 

The Enhanced Recovery After Surgery (ERAS) protocol begins at least one week prior to surgery with a diet rich in carbohydrates and protein as well as hydration with sports drinks.  On surgery day, a patient receives oral medications designed to reduce pain by working in several different ways: an anti-inflammatory medication reduces swelling; a neuro-modulating medication blocks pain receptors; and a long acting narcotic reduces actual pain. In addition, an adductor canal catheter is inserted preoperatively and connected to a pump for up to 48 hours of post-operative pain control.

The ERAS protocol further enhances pain management by intraoperative injection of the knee capsule with a mixture of bupivacaine with epinephrine and ketorolac.  Post-operatively, the anti-inflammatory, neuro-modulating and narcotic medications are continued. 

Using this multimodal technique, post-operative pain is controlled well enough to allow the patient to ambulate in physical therapy within a few hours of surgery and to leave the hospital setting within a day or two.  The patient may still require oral narcotic analgesics in the early post-op period, but narcotics are quickly weaned and the patient is transferred to non-narcotic medications typically by six weeks post-op.

"Orthopaedic surgeons across the country regularly perform procedures that make a difference in a person's life, but comes with some degree of pain while recovering," he says.  "With the ERAS, we are partnering with our patients to reduce post-operative pain and to quickly return them to their active lives." 

Mackenzie Moran of Carlisle, Pa., is a lacrosse player at Baldwin Wallace University in Ohio, who early in the 2016 season tore both her ACL and meniscus. She's also a patient whose doctors used a combination of therapies – before, during, and after surgery – to address pain.

Hours after her surgery she was home resting, and within days back in classes at Baldwin Wallace.

"Recovery isn't fun, and some pain was part of my experience," she says. "Between my team doctor from the Cleveland Clinic, athletic trainers at Baldwin Wallace, my surgeon at Penn State, and a physical therapist in my hometown, I had a plan that included a variety of ways to ease my pain ranging from a nerve block to ice.  I really only used Percocet for a short time and everyone encouraged me to minimalize using it."

'Be Smart. Be Safe. Be Sure.' Launches

Back at the Pennsylvania Medical Society, Dr. Shapiro sees a need for greater patient empowerment as part of the solution to the country's opioid crisis. 

"It's as much a part of the answer as physician education, prescribing guidelines, and opioid tracking," he says. "Patients will see prescribing patterns change and alternative options tried to reduce opioid use. That's going to be the new expectation instead of relying so heavily on opioids."

As such, Dr. Shapiro's organization launched a patient empowerment advocacy program in May titled "Opioids for Pain: Be Smart. Be Safe. Be Sure."

According to Dr. Shapiro, the initiative will educate the public through physician offices and state politicians who offer health and senior fairs. Social media will also be tapped.

"Patients in pain deserve care and compassion," says Dr. Shapiro. "Treating pain is among the most difficult – and most common – reasons patients come to us."

"As physicians, we are often under pressure to 'satisfy a patient's pain' and sometimes this requires prescribing an opioid," he says. "But caring also means sometimes saying no and recommending an alternative course of treatment – no matter how difficult that may be."

Dr. Shapiro says the initiative will encourage patients to ask their doctors several important questions when a prescription is written. Questions include

Is this prescription an opioid? At what level of pain should I take this prescription? Do I have to take every pill in the prescription? Where can I safely dispose of remaining pills? What can I do to avoid addiction? What are possible warning signs of dependence or addiction? What can I do if I believe that I might have developed a dependence on this drug?

"Ultimately, when it comes to opioid use, patients and their doctors need to be smart; they need to be safe; and they need to be sure," says Dr. Shapiro. "That's our key message."