Most Americans understand, at least in part, how bad the opioid crisis has gotten. But, to review: In 2015 alone, opioid overdoses claimed more than 42,000 lives in America, which is more than 500 percent increase over the number of opioid-related deaths in 1999.
Even more troubling, 75 percent of people who abuse heroin now say they got their start abusing prescription drugs. Studies show that over 50% of people who abused prescription painkillers got them from friends or relatives for free; 25% of them received it from a doctor.
As a surgeon-in-training who constantly prescribes both inpatient and outpatient pain killers, these figures are more than just a little alarming. And after a long day, I’ve often found myself asking the sobering question: Am I contributing to the opioid epidemic?
In part because of my own concerns, in my department at Duke University Hospital, I was recently tasked with developing a new pain protocol to try and standardize our post-operative pain regimen in order to limit the amount of narcotics given to patients. The overarching goal is simple: To only give opioids to those who really need them, in as sparing an amount as possible.
After a long day, I’ve often found myself asking the sobering question: Am I contributing to the opioid epidemic?
But even with the opioid epidemic splashed across media headlines nationwide, this mission has proven to be far more difficult than most might imagine, and it has even made me very unpopular among some of the staff and doctors of my own hospital.
The problem, of course, is that, in many ways, it is so much easier to over-medicate patients, especially those who struggle with pain that can interfere with emotional and physical recovery. Giving patients what they want for pain makes for a much more enjoyable hospital stay for them, and an easier patient for us to take care of.
But when I examined the available research on opioid-related deaths and addiction, it became clear that despite the extra discomfort some might feel, in the end, many patients are better off without opioids, even if it means more discomfort.
For interventionalists and surgeons, appropriately and effectively managing postoperative pain has always been a challenge. None of us joined this profession to hurt people, and it feels natural to treat the pain that we see in front of us each day as aggressively as possible. Many of my patients have cancer, deformities, infection and/or other pathologies that violate tissue and destroy anatomy. We see patients suffering, and our reflex as doctors is to help them.
Despite the extra discomfort some might feel, in the end, many patients are better off without opioids, even if it means more discomfort.
(Additionally, doctors may face many other external pressures to treat pain, since pain control is part of several metricsincluded in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which is linked closely to Medicare reimbursements.)
Unfortunately, treating pain often has its own complications. For instance, studies have consistently shown that opioid use in the hospital is often associated with an increase in inpatient mortality and aggregate morbidity, including respiratory failure, surgical site infection, mechanical ventilation, pneumonia, myocardial infarction, and postoperative ileus (when your intestines stop contracting), as well as prolonged hospital stays and non-routine discharges. In other words, giving a patient opioids to treat post-operative pain can make them sicker.
And in April 2017, researchers at the University of Michigan released the results of a population-based study of 36,177 surgical patients which found that there is a small but significant proportion of patients who develop new and persistent opioid use, beyond what is to be expected for pain relief, after both major and minor elective surgeries. They called persistent prescription opioid use “one of the most common complications after elective surgery.” These findings have been replicated in other studies, and in many different surgical fields, too.
What can health care providers do to address these problems?
For one, we should look abroad. In numerous other countries, opioid use is much lower than it is in the United States, even though the physicians there do many of the same surgeries. This is likely because patients receive far, far fewer opioid medications in and out of the hospital, due to costs, availability and doctor preferences. I’m sure that some patients have a more painful experience in those countries than they would here, but in the big picture, and, as difficult as it is to practice, maybe a little more discomfort is what some of our patients need to spare them some of the widely-recognized complications of opioid-based pain management.
Researchers called persistent prescription opioid use “one of the most common complications after elective surgery.”
This is not to say that patients should be left writhing in pain in their hospital beds: We need to start using a multi-disciplinary and multi-modal approach to pain management. Surgeons need to engage in early education with their patients about post-operative pain management and the risks of medications, as well as setting realistic expectations about what post-surgery pain will be like.
Additionally, health care providers need to identify those most vulnerable to opioid addiction, including those with mental health issues or pre-existing substance abuse, and establish more sensitive processes that ensure they experience as little pain as possible without relying on potentially dangerous opioids.
We also need to rely more heavily on other medications in our arsenal, such as acetaminophen, non-steroidal anti-inflammatories, muscles relaxants and nerve agents. And health care providers need to be innovative and creative and find different ways to implement pain medication delivery, using methods like steroid injections and epidural catheters.
Providers must also work harder to encourage those who do develop addictions to enlist in rehabilitation, and they should involve more frequently other specialists in crafting and carrying out treatment plans, especially pain management doctors and psychologists.
Most importantly, all providers need to look in the mirror and ask themselves if we are being good stewards of prescribing practices, or if we are part of the problem we see in the news.