Fewer Opioid Painkillers Can Still Control Surgery Pain

Surgery patients can routinely be prescribed fewer opioid pills - even just a handful - without sacrificing their pain relief.

That's what doctors at hospitals in Michigan are reporting after analyzing a statewide effort to curb post-surgery opioid use.

In the months after new guidelines went into place, 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.

That's important, researchers said, because the goal is to put the brakes on excessive prescribing without leaving patients with untreated pain.

"This isn't just about reducing opioid use," said lead researcher Dr. Joceline Vu, a surgical resident at the University of Michigan in Ann Arbor. "It's also about giving patients the best care for their pain."

After years of skyrocketing, prescriptions for opioids have been declining in the United States since 2012, according to the U.S. Centers for Disease Control and Prevention. That has been in response to the opioid abuse epidemic - which, government figures show, is currently killing more than 130 Americans every day.

Illegal opioids, such as heroin and illicitly manufactured fentanyl, have become the biggest concern in recent years.

Still, prescription opioids - like OxyContin, Vicodin and Percocet - were involved in 36% of opioid overdose deaths in 2017, according to the CDC.

When it comes to prescribing opioids for post-surgery pain, there are no national guidelines on "how much," according to Vu. At one time, she said, it was routine for patients to go home with prescriptions for 30 to 60 pills.

The problem with that is not only that patients will take more medication than needed; it's also the leftover pills that can end up being used - or abused - by someone else.

"Surgery prescriptions are a major source of leftover pills," Vu said.

In addition, some patients become "long-term users." An earlier University of Michigan study found that among surgery patients who were prescribed opioids (and had not been using them before the operation), 6% were still on the painkillers three to six months later.

So, a collaboration known as the Michigan Opioid Prescribing Engagement Network came up with guidelines on the number of pills that should be prescribed for individual surgeries.

Currently, they recommend no opioids after pulling wisdom teeth; and anywhere from zero to 5 or 10 pills for a range of surgeries -- appendectomy, hernia repair, and breast tumor or prostate removal.
With certain surgeries -- such as some heart procedures, a cesarean section, or hip or knee replacements -- up to 20, 30 or 50 pills might be prescribed.

The guidelines were released to 43 hospitals in October 2017. Over the next seven months, Vu's team found, the number of opioid pills prescribed dropped by to an average of 18 pills, from 26 in the months before the guidelines.

Based on surveys of nearly 6,600 patients, there was no change in satisfaction ratings or pain scores.
The findings are reported in the Aug. 15 issue of the New England Journal of Medicine.

"This shows how a relatively simple intervention, at the state level, can make a difference," said Dr. Allan Gottschalk, a professor of anesthesiology at Johns Hopkins University.

Individual patients, of course, differ in their experiences of pain, said Gottschalk, who was not involved in the study. He suggested that patients gearing up for surgery talk with their doctor about what to expect afterward, and discuss their options for pain relief.

That conversation is vital, according to Dr. Robert Duarte, director of Northwell Health's Pain Center in Great Neck, N.Y. He was not part of the study.

Sometimes, Duarte said, patients think opioids are the only way to deal with surgical pain. But the alternatives include acetaminophen and ibuprofen, plus medications that people "don't think of as painkillers," such as certain antidepressants or the anti-seizure drugs gabapentin and pregabalin.

For lingering pain, Duarte said, physical therapy and muscle strengthening may help.

He also pointed to the importance of having "reasonable expectations."

"If you had chronic pain from arthritis before the surgery," Duarte said, "a knee replacement might reduce the pain, but it may not go away entirely."

Simply arming patients with information, he said, may help reduce their opioid use.

Sources: Joceline Vu, M.D., surgical resident, University of Michigan, Ann Arbor; Allan Gottschalk, M.D., Ph.D., professor, anesthesiology and critical care medicine, Johns Hopkins University School of Medicine, Baltimore; Robert Duarte, M.D., director, Pain Center, Northwell Health Institute for Neurology and Neurosurgery, Great Neck, N.Y.; Aug. 15, 2019, New England Journal of Medicine