Prioritizing Patient Pain Before Surgery Can Help Change the Trajectory of the Opioid Epidemic

Hoping to turn the tide of the devastating opioid crisis that continues to ravage our nation, 2023 promises to be a historic year. The new federal budget specifically earmarked $1.5 billion to support opioid addiction and recovery programs in all 50 states and US territories, and commited a record $42.5 billion to National Drug Control Program agencies.1,2 That money is aimed, in large part, at thwarting drug traffickers, who continue to funnel vast amounts of synthetic opioids like fentanyl onto our streets.

While more attention and unprecedented resources like this will undoubtedly help to address the opioid crisis, it’s clear we need to do even more to end it. I’m proud to lead one team of surgeons in Ohio who are determined to do just that.

The Challenge

There are many sources of natural and synthetic opioids, of course, and certainly a myriad of reasons that people develop an addiction to them. What troubles us, as physicians and health care providers, are those patients whose addictions begin, unwittingly, as legally-prescribed, well-intended treatments.

In 2020, the worst year yet of the opioid epidemic, nearly 1 out of every 4 overdose deaths came from legally prescribed opioids.³ In all, 16,000 Americans lost their lives from misusing opioid prescriptions—that’s an average of about 1 death every 30 minutes.

Determined to do our part to change those numbers, we developed initiatives to prioritize our patients’ pain before surgery and offer them strategies to better manage it afterwards. Since the launch of our program, we have cut opioid use in half in our surgical patients, and dramatically shortened the amount of time they spend in the hospital. Now, other health care programs are looking to implement these initiatives, designed specifically to stop addictions before they ever start.

The Scope of the Problem

Though they have been well documented over the last 2 decades, the numbers are simply staggering. Since 1999, overdoses involving opioids have claimed the lives of more than 600,000 Americans.⁴ In one year alone, during the height of the pandemic, there were more than 68,000 overdose deaths, up 38% from the year before, and preliminary data from this past year indicate that opioid-related deaths continue to rise.⁵

In all, since the start of the opioid crisis, deaths from overdoses are up an astounding 500%. That’s the human toll.

The economic toll that opioids have on this country is also crippling. According to the Joint Economic Committee, in 2020 alone, the opioid crisis cost $1.5 trillion—up 37% from 2017, the last year the CDC measured such costs.⁶

How Did We Get Here?

This all began a generation ago when pain management became a greater focus for physicians.⁷ In 1995, the influential American Pain Society dubbed patient pain “the fifth vital sign.” It may have started as a well-intended effort to better care for patients, but a cascade of catastrophic events soon followed. Within a few years, The Joint Commission, which accredits tens of thousands of hospitals and health care organizations in the United States, established novel guidelines for pain management.

Sensing an opportunity to increase profits, some pharmaceutical companies launched risky and reckless campaigns urging doctors to prescribe opioids more freely. Wanting to remain compliant and in good standing with the Commission, many doctors did, and the deadly cycle of addiction had begun.

Soon, prescriptions were written, not only for acute pain following surgery, but for chronic pain and for any number of conditions. At one point, 12 states in the Midwest and the South had more prescriptions written for painkillers per capita than they had residents. For every 100 people in Tennessee, for example, there were 143 prescriptions for painkillers.⁸

By 2017, the US government declared the opioid epidemic a public health crisis and began to strictly curb prescriptions. Many of those who could no longer get painkiller prescriptions legally turned to synthetic opioids like heroin and fentanyl, and the crisis worsened.

It was around that time that our team began to formulate our initiatives. We knew there were millions of Americans struggling with addiction whose first experience with opioids stemmed from legitimate medical necessities. While we couldn’t control every aspect of this crisis, we knew there had to be better ways to manage our patients’ pain than to subject them to the risks of opioid addiction.

Our Approach to Pain Control

One of the keys to our approach is to incorporate pain control at the outset of any surgical consultation. Because we care for cancer patients our ultimate objective when it comes to surgery, of course, is to remove tumors and cancerous tissue, and to mitigate any further damage they might cause. In the past, unfortunately, the pain associated with surgical recovery was all too often an afterthought—but not anymore.

To be clear, opioids are a powerful and effective option for managing acute pain associated with surgery, and we still prescribe them to our patients. However, we view them as one option among many to control pain, and we work to build recovery plans based on the careful limitation of their use.

The plan we developed at The Ohio State University Comprehensive Cancer Center calls for critical steps to be taken before, during, and after surgery:

Prior to surgery

We evaluate patients and assess their ability to take the pain reliever acetaminophen prior to surgery. It may seem counterintuitive but loading up on pain relievers before surgery can help patients stay ahead of pain afterwards.

Unlike aspirin, ibuprofen, and other nonsteroidal anti-inflammatory medications, acetaminophen does not thin your blood, which can be risky heading into surgery. Also, taking larger doses of up to 3000 to 4000 milligrams the day before surgery can help to offset post-surgical pain, because it can safely stay in your system for more than 24 hours.

During surgery

Our teams employ the use of nerve and regional blocks to control pain during surgery. The National Institutes of Health succinctly outlines the many advantages to this approach over relying only on general anesthesia, including faster recovery times, the avoidance of airway manipulation during surgery, and fewer adverse effects than systemic drugs.⁹

The use of opioids during and immediately after surgery can cause nausea and breathing problems, and in some patients, the GI tract doesn’t “wake up” as quickly following surgery. Most importantly, patients who get nerve and regional blocks report much lower pain levels after surgery and are able to get into physical therapy much sooner.

After surgery

Nerve and regional blocks can continue in some patients post-operatively as a pain control strategy, but whenever appropriate, we also start them on effective and non-habit forming over-the-counter medications like ibuprofen or naproxen to help control inflammation.

However, one of the most critical aspects of our post-operative program is that we insist on safely limiting bedrest and encouraging exercise and physical therapy as soon as possible.

Our colleagues at The Ohio State University James Cancer Hospital have teams that specialize in oncology rehabilitation to help patients improve things like balance, strength, and blood flow, and better control challenges associated with surgery and cancer treatments such as depression, anxiety, and fatigue.¹⁰

Overall, we have cut the time patients spend in the hospital following surgery by 25%, and by viewing opioids only as a last resort to manage pain, we have cut their use in half. The results have been so encouraging that our opioid sparing initiative is now being implemented in 10 other programs throughout our medical system.

We have a long way to go to turn the tide in this crisis, but by taking a different approach to managing pain, we are doing our part to reduce the risk of addiction one patient at a time.

About the Author

Michelle Humeidan, MD, PhD, is a native of Columbus, Ohio and completed the MD-PhD program at the University of Kentucky in 2011. A diplomate of The American Board of Anesthesiology, Humeidan completed an internship, residency, and a fellowship in Neuroanesthesiology at The Ohio State University Wexner Medical Center and joined the Faculty in 2015. She is currently medical director of Enhanced Surgical Recovery and is committed to minimizing use of perioperative opiates. Humeidan also focuses on neurological research, both preclinical and clinical. She is primary investigator for the Neurobics Randomized Clinical Trial exploring use of cognitive prehabilitation for postoperative delirium prevention. Humeidan is committed to optimizing perioperative management of patients to facilitate the best possible functional recovery after surgery.

References

1. The White House. FACT SHEET: Biden-⁠Harris Administration Announces New Actions and Funding to Address the Overdose Epidemic and Support Recovery. 2022. Accessed February 7, 2023. https://www.whitehouse.gov/briefing-room/statements-releases/2022/09/23/fact-sheet-biden-harris-administration-announces-new-actions-and-funding-to-address-the-overdose-epidemic-and-support-recovery/
2. The White House. President Biden Calls for Increased Funding to Address Addiction and the Overdose Epidemic. 2022. Accessed February 7, 2023. https://www.whitehouse.gov/ondcp/briefing-room/2022/03/28/president-biden-calls-for-increased-funding-to-address-addiction-and-the-overdose-epidemic/#:~:text=WASHINGTON%2C%20D.C.%20%E2%80%93%20Today%2C%20President,deaths%2C%20driven%20primarily%20by%20illicitly
3. CDC. Drug Overdose. 2022. Accessed February 7, 2023. https://www.cdc.gov/drugoverdose/deaths/prescription/maps.html
4. CDC. Opioids. 2022. Accessed February 7, 2023. https://www.cdc.gov/opioids/basics/epidemic.html
5. CDC - National Center for Health Statistics. Provisional Overdose Death Counts. 2022. Accessed February 7, 2023. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
6. Joint Economic Committee Democrats. 2022. Accessed February 7, 2023. https://www.jec.senate.gov/public/index.cfm/democrats/2022/9/the-economic-toll-of-the-opioid-crisis-reached-nearly-1-5-trillion-in-2020
7. Jones MR, Viswanath O, Peck J, Kaye AD, Gill JS, Simopoulos TT. A Brief History of the Opioid Epidemic and Strategies for Pain Medicine. Pain Ther. 2018 Jun;7(1):13-21. doi:10.1007/s40122-018-0097-6
8. CDC. Opioid Painkiller Prescribing Infographic. 2012. Accessed February 7, 2023. https://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html
9. Folino TB, Mahboobi SK. Regional Anesthetic Blocks. [Updated 2022 Jul 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Accessed February 7, 2023. https://www.ncbi.nlm.nih.gov/books/NBK563238/.
10. The Ohio State University Comprehensive Cancer Center, James Cancer Hospital. Accessed February 7, 2023. https://cancer.osu.edu/for-patients-and-caregivers/learn-about-cancers-and-treatments/clinical-services-at-the-james/oncology-rehabilitation