Web Log – September 2017 – Opioids and Surgery

As defined by Wikipedia, Opioids are substances that act on opioid receptors to produce morphine-like effects. Medically they are primarily used for pain relief, including anesthesia.  Commonly used legal ones are morophine and variations like oxycodone.  An illegal one is heroin.  Opioid addiction is now considered a national health emergency and opioid use is closely scrutinized.  So, what does this have to do with surgery?  Good question.

 

We doctors try to minimize pain because we are human beings who don’t like to see patients suffer – that much is obvious.  Also, accreditation agencies a few years ago defined pain as a vital sign, so pain control effectiveness is a priority that is being evaluated.  Finally, don’t forget about those satisfaction surveys and patient word of mouth.  If your family practice doctor or ER physician don’t provide pain medication for non-surgical pain, patients are unhappy.  This has all lead to the proliferation of chronic opioid use.

 

Unfortunately, surgery causes pain.  I and all surgeons try to minimize pain by providing opioids post operatively.  I also use local anesthetics during the operation, and when appropriate, long acting ones as well.  I like to avoid NSAID’s ( Motrin, Alleve ) right after the operation to avoid increased risk of bleeding. This medication class makes blood platelets not function well.  A related drug, however, is Celebrex.  It really helps with pain control and does not cause bleeding problems. In by experience, it seems to decrease opioid use quite well.  This is great because it minimizes the opioid side effects like nausea, sedation, and constipation.  Insurance companies, however, will not approve it for short term use, so it is an out of pocket expense for most patients.  We provide patients with an information sheet on how to minimize prescription cost.

 

Nonetheless, patients need opioids after operation.  Some may need more than others and longer than others.  The only time I have had patients have a problem stopping opioids is when they had a current pain medication requirement for a chronic condition like back pain or history of abuse problem before the operation was done.  This remains fairly rare.  Policies to minimize opioid use among the general patient population, however, makes it more difficult and stigmatizing to provide appropriate pain relief to post operative patients.

 

Finally, a study came out confirming what surgeons have known all along… long term opioid use rarely starts with a surgery.  In fact, only 0.4 % ( 4 of 1000 ) of long term opioid users started with an inpatient surgical procedure.  I would be willing to bet even fewer had an outpatient procedure like the overwhelming majority of my patients have.  Here is a link to a New York Times article on the subject.  I like that it starts with, ” Don’t blame the surgeons…”  So, I would conclude, I want to minimize opioid use for my patients, but if you need some pain medicine, take some.  You don’t get a blue ribbon for being any more uncomfortable than necessary.

 

Mark D. Wigod, MD, FACS, providing Cosmetic and Reconstructive Plastic Surgery to Boise, Meridian, Treasure Valley and Southeastern Idaho.

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