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Two VA patients were discharged from the hospital on the same day. One, a 70-year-old retiree, had an arthritic knee replaced. The other, a 24-year-old auto mechanic, underwent a hernia repair.
The woman and man (names are being withheld to protect patient privacy) came to the operating room for very different reasons. However, both left the hospital with an item that patients all too often take home: a sizable supply of prescription opioids. One year after surgery and unknown to their surgeons, both are still taking painkillers.
No one goes into an operation hoping to be on opioids a year later. In some cases, chronic use of opioids after surgery is unavoidable. But all too often, opioids are excessively prescribed. Up to 75 percent of patients, if not more, after surgery have leftover painkillers.
In many cases the continued use of these drugs after surgery doesn't receive the same scrutiny as when they are used for chronic pain. Even for standard procedures, like a hernia repair, there is wide variation in the amount of opioids that patients take home — variation that is hard to explain based on patients’ characteristics, or the scientific evidence.
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With as many as 10 percent of patients still using opioids a year after surgery, chronic opioid use has become one of the most common and serious long-term risks of undergoing an operation. It is time to stop treating the prescribing of opioids after surgery unquestioningly, a practice we refer to as "surgical exceptionalism." Post-op prescribing — like the use of opioids for chronic, non-cancer pain — deserves greater scrutiny.
By the early 2000s, general clinical teaching suggested that the risks of addiction or misuse from opioids had been overblown. This assertion was especially held for patients with “organic” pain easily explained by injury or ailment of a body part. The best case for enthusiastic use of opioids was often surgery. The cause of the pain was clear. Clinicians were also eager to take away the “organic” pain they had just created in the operating room.
Patients can become addicts
A growing body of evidence, however, now indicates that a significant portion (6% to 10%) of patients without opioid use prior to an operation end up on long-term opioids. It would be one thing if such patients fared well, and if the scientific evidence supported such use. But in fact, there is scant evidence for the safety or effectiveness of opioid use for chronic post-operative pain. Data increasingly suggest that chronic opioid use after surgery is associated with the same problems often seen with opioids used to treat chronic, non-cancer pain: prolonged use with increased risks for misuse, addiction and overdose.
Though the risk of chronic use may be relatively low in any single patient about to undergo knee replacement or a hernia repair, the absolute number of patients is large given the millions of surgeries that are performed annually in the U.S. Even for patients who don’t transition to chronic use, many end up with a large quantity of unused pills. This reservoir of opioids creates challenges, including difficulties around safe storage, disposal and potential diversion to family and friends.
In addition, clinical follow-up of potential surgical complications can often be improved when patients have a smaller, initial number of doses. As a result, professional societies and government agencies are increasingly interested in addressing postoperative opioid prescribing.
Doctors have many tools
The good news is that reducing surgical opioid use need not compromise patients’ quality of care. In fact, the more we learn about the risks and benefits of opioids after surgery, the more it becomes clear that, just as in non-surgical settings, we’ve tended both to overestimate the benefits of opioids while underestimating their risks. Patients and surgeons have many tools to choose from, and the time for such discussions is before an operation.
Some patients achieve adequate pain control with ibuprofen or a topical pain reliever right after an operation. Yet others may benefit from regional anesthesia, where an injection using a medicine like novocaine is placed close to a nerve to relieve the discomfort. Longer term, others may benefit from additional non-pharmacologic therapies such as physical therapy, massage or acupuncture.
A comprehensive response to the opioid epidemic must consider all of the settings in which these drugs are overused. For many patients, the most important setting is after they have an operation. We are at a unique moment in moving forward to address the opioid crisis. We must not leave surgical patients behind.
Dr. Sesh Mudumbai, an assistant professor of anesthesiology at Stanford University and a staff anesthesiologist at the VA Palo Alto, investigates how medications like opioids are managed and used. Dr. Randall Stafford, a professor of medicine at Stanford University, practices primary care internal medicine and studies strategies for improving patterns of drug prescribing. Dr. G. Caleb Alexander is an internist and pharmacoepidemiologist at Johns Hopkins Bloomberg School of Public Health. Their views do not necessarily reflect those of the Department of Veterans Affairs (VA) or other institutions.
This article originally appeared on USA TODAY: Having surgery? Beware of risk from post-op opioids
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