Managing Post-Op Pain Safely

AS A MEDICAL STUDENT almost 20 years ago, the message was clear: Addiction to opioids was unlikely if the patient had "real" pain. Little did we know that this messaging would come back to haunt millions in this country. Very little time was spent on pain-management strategies in medical school. As a resident, even less: We would just write what each attending deemed appropriate, a practice that is still common today.

In 2016, Massachusetts became the first state to pass a law limiting opioid prescriptions to seven days. Now, more than 33 states have enacted legislation related to opioid prescription limits. The limits vary widely by state, from a low of three to four days (Florida, Tennessee and Kentucky) to 14 days (Nevada). Why the disparity? Noble efforts to limit prescribing by law have not included the education required to achieve such difficult cultural change. A prescribing "habit" is hard to break.

Why limit prescribing? We now know that over-prescription is a major contributor to the opioid crisis. Unused opioids can find their way into the wrong hands, whether it be friends and family or strangers on the street. The non-medical use of these prescription drugs can lead to exposure to illicit drugs such as heroin or cocaine, which can be deadly.

Drug enforcement officers I've spoken to in Ohio tell a chilling tale: "I've not seen pure heroin in more than two years." Fentanyl and carfentanil are up to 1,000 times more potent than morphine and are commonly cut in with heroin, cocaine and other street drugs. The presence of these powerful synthetic opioids explains the exponential rise in overdose deaths that we have seen recently in this country.

Over the past year at the Cleveland Clinic, we've reduced opioid prescriptions by 40% through major multidisciplinary initiatives. Because systemic and cultural change is difficult for both health care providers and patients, we as a nation need to keep having these conversations if we want to turn the tide on the opioid crisis.

What can you do as a patient to manage your acute or post-operative pain safely and appropriately?

Be your own advocate. Make sure to have a conversation with your physician, surgeon and anesthesiologist about what to expect. Setting appropriate expectations and discussing options prior to surgery is essential. Besides oral or IV medications, many anesthesiologists offer advanced options such as ultrasound guided nerve blocks or catheters that can numb different areas of the body without the use of opioid-type medications. At the Cleveland Clinic, anesthesiologists and surgeons work together to create a pain-control plan tailored to each patient prior to surgery.

Understand the three tiers of pain treatment options.

1. First tier: Non-pharmacologic therapy. Not all pain management requires medication. Meditation, relaxation, music therapy, acupuncture, massage and even pet therapy can help alleviate mild pain. Ongoing research using virtual reality (distraction) has shown promise.

2. Second tier: Non-opioid medications should be viewed as the primary choice for pain control. Up to 1,000 milligrams of Acetaminophen or Tylenol can be taken every six hours (4,000 milligrams per day). Non-steroidal anti-inflammatory agents such as ibuprofen, ketorolac or aspirin may be appropriate for some patients. Acetaminophen should be taken with an NSAID when possible – they work great together. Local anesthetics can be used to numb different areas of the body and are available as an injection or a patch.

3. Third tier: Opioids. The smallest effective dose can be used for as short a course as possible.

Maximize non-opioid medications. Non-opioid medications should be maximized so that need for opioids is reduced. Opioids should only be used for breakthrough pain, which is a sudden increase or spike in pain above and beyond what the therapies in tier one and two can provide. The important thing is that using an opioid doesn't mean you discontinue second tier medications or first tier therapies. Limiting your exposure to the opioid decreases your chances for developing opioid-related side effects and the risk for addiction. At Cleveland Clinic, we found that if cesarean patients were given maximal doses of non-opioids (Acetaminophen and Motrin), they chose to use 70% less opioids

By Eric Chiang, M.D

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