Misuse is a possibility.
Recovering from major surgery is difficult. Incisions that cut through muscles, nerves, organs and bones make pain almost inevitable. Once the anesthesia wears off, opioid medications such as morphine, fentanyl, OxyContin and Percocet can make post-op pain more bearable. However, when patients leave the hospital still taking powerful pain pills — or when opioid drugs are routinely prescribed after outpatient surgeries — it’s not always safe. A massive study looked at more than 1 million surgical patients who hadn’t previously used opioids. After hospital discharge, of the nearly 570,000 patients who received opioids, each refill and each week of follow-up prescriptions was associated with a large increase in opioid misuse, according to the study published in January in BMJ. As the opioid crisis continues, experts say nonopioid alternatives should play a bigger role in treating post-surgical pain.
Ibuprofen and acetaminophen
Patients could manage pain on nonsteroidal anti-inflammatory drugs alone after certain procedures. NSAIDs such as ibuprofen (Motrin and Advil), acetaminophen (Tylenol) and naproxen (Aleve and Naprosyn) can work just as well, research suggests. A small, randomized controlled trial compared patients who received either opioids or NSAIDs after carpal tunnel surgery. Neither patients nor doctors knew which they received. No difference was seen in patients’ pain experience or the number of pills they consumed, according to the study presented at the annual meeting of the American Academy of Orthopaedic Surgeons in March. Among different types of surgery, including more complex and painful procedures, “It’s often these more common, high-volume, low-intensity surgeries are the ones that tend to result in dependency,” says study co-author Dr. Asif Ilyas, program director of the hand surgery fellowship at the Rothman Institute. He points to other, immediate advantages of avoiding opioids. Patients can bypass side effects such as drowsiness, nausea and voting, itching and constipation, and restrictions on driving or using heavy machinery.
Preoperative counseling
If you’re considering surgery, make sure to ask about pain relief in advance. Knowing what to expect before surgery prevents patients from being blindsided by postoperative agony or discomfort. “I go into a good amount of detail with all my patients about pain management and their pain experience after surgery, and about opioids,” says Ilyas, who is also a professor of orthopedic surgery at the Sidney Kimmel Medical College at Thomas Jefferson University. In addition, patients watch a video with postoperative instructions. “Patients should ask for some insight on the amount of anticipated pain afterward, so that they’re prepared for it, and [about] a strategy to manage that,” he says. That way, they won’t be caught off guard. “In general, I find that the more patients are counseled, educated, informed and prepared, the better they manage pain,” he says. Such patients are less likely to feel overwhelmed, he adds, or to immediately seek opioids for relief.
Multimodal methods
Tackling surgical pain with a multipronged approach can reduce overdependence on opioids. “The current thinking is that we should be using what we call ‘multimodal strategies,'” says Dr. Roger Chou, a professor of medicine in the division of general internal medicine and geriatrics at Oregon Health and Science University. “We’ll use different medications and also different ways of delivering the therapies,” says Chou, an author of 2016 guidelines for management of postoperative pain. Preoperative counseling is one facet. During surgery, using regional anesthesia such as epidurals and nerve blocks avoids systemic side effects. In recovery, nonopioid medications, such as gabapentin and pregabalin, NSAIDS and acetaminophen, can replace or reduce opioid use. Patients are also encouraged to try nonmedication, alternative methods.
Alternative and supportive techniques
Acupuncture, massage, guided imagery and relaxation techniques are some nonmedication ways to manage pain. Transcutaneous electrical nerve stimulation, or TENS, involves applying mild electrical pulses to affected body parts to ease surgical pain. Cognitive behavioral therapy, a combination of talk and behavioral therapy, can help reduce post-op pain, suggests a study released in January 2018 in the journal Patient Related Outcome Measures. Supportive measures such as elevating the affected arm or leg, applying ice and wearing a brace are proven ways to promote healing after orthopedic surgery.
Dental check
Until recently, dental patients sometimes received prescriptions for several weeks of opioid pills after oral surgery like root canals. In the April 2018 issue of the Journal of the American Dental Association, several studies probed opioid prescribing practices among U.S. dentists. Prescribing rates increased slightly from 2010 through 2015 — with nearly one-third of prescriptions related to nonsurgical dental visits. A mega-analysis of evidence concluded that acetaminophen and NSAIDs are equal or superior to opioids for treating dental pain. On March 26, the American Dental Association announced a new policy supporting mandatory continuing education for dentists in prescribing opioids and other controlled substances. The policy also supports mandatory limits on opioid dosages and duration of no more than seven days to treat acute pain.
Extra caution for kids
Children and teens who undergo surgery for sports injuries or other conditions may respond differently physically to opioids than adults. Another issue is the possibility of later drug misuse or diversion. A January 2018 study in the journal Pediatrics found that even legitimate use of opioids before high school graduation is tied to increased risk for future opioid misuse. Before kids undergo surgery, parents should discuss pain management strategies with their doctors. Opioids should be reserved for kids in moderate to severe pain, with short-acting opioids used first, according to guidelines for safe prescribing. The smallest effective dose should be used, and opioids should be discontinued when ineffective. For mild to moderate pain, alternatives like NSAIDs are preferable. Non-medication methods including heat and cold application, exercise, art and play therapy and distraction can help kids cope with pain.
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6 Nonopioid Ways to Ease Postoperative Pain originally appeared on usnews.com
