Ask surgeons and anesthesia providers how they manage post-operative pain, and ambivalence regarding opioids is likely to quickly become apparent. Our recent survey shines a bright light on that ambivalence. The responses we got form a nearly perfect bell curve, with the vast majority somewhere in the middle, seemingly searching for the sweet spot that perfectly balances the benefits of opioids with their drawbacks.

To gauge providers' attitudes, we gave them 4 choices. At one extreme were a defiant 9% who chose, "They're still the best way to manage pain, and when called for, they're my first choice." At the other extreme were 9% who said they consider using opioids "only as a last resort."

And in between were the more than 80% combined who acknowledged concerns, but who won't relegate opioids to "last resort" status — 43% who said they're "open to reducing opioid use, but don't hesitate to use opioids when patients face real pain," and 39% who said they're "actively trying to reduce opioid use, but that opioids still have a role to play."

Overall, the numbers are good news to nationally renowned pain expert Eugene R. Viscusi, MD, professor of anesthesiology and director of acute pain management at Jefferson University in Philadelphia, Pa. "I think the themes among anesthesia and surgery are pretty consistent, and those are that there's a move away from opioids," says Dr. Viscusi, an early and outspoken proponent of multimodal analgesia. "Both the nuisance side effects and the bigger problems related to sending patients home with opioids have made their way into mainstream thinking."

The side effects are well documented — from "nuisances" like constipation and nausea, to potentially life-threatening events like addiction and respiratory depression.

Still, some suggest that the increasingly negative tone around opioids has gone too far. "Narcotics are not intrinsically evil," says Louis G. Stanfield, CRNA, PhD, DAAPM, of the Mercy Medical Center in Sioux City, Iowa. Dr. Stanfield says he's open to reducing opioids, but that he doesn't hesitate when he thinks they're called for. "Multimodal analgesia implies the use of multiple agents for analgesia," he adds. Of which, of course, opioids are one.

Dr. Viscusi agrees. "The ideal in my mind is to use around-the-clock acetaminophen, non-steroidals, pregabalin and local or regional anesthesia as a base, and then have the opioid become the PRN," he says. "The ASA 2012 guidelines on the subject of multimodal analgesia don't preclude opioids — they preclude opioids as a standalone or first-line agent."

But inevitably there are other views. Surgeon Jeffrey Blank, DPM, of Foot First Podiatry in Crystal Lake, Ill., counts himself among those for whom opioids are often a first choice, and the reason is simple. "A lot has to do with patient expectations," he says. "If they expect an opioid, and in their mind nothing else will work as well, I give them a few days of an opioid and then switch them to something else." But Dr. Blank notes that peripheral blocks and infiltration are also key components of his practice. He's in the vast majority in that regard, as we'll discuss.

Still, the willingness to reach for opioids as a primary agent isn't unusual, says Gary Lawson, MD, chief medical officer at Quantum Anesthesia in Sarasota, Fla. "Surgeons still primarily prescribe opiates for post-op home use," says Dr. Lawson, who favors acetaminophen and NSAIDs and, like Dr. Viscusi and others, counsels an "if-needed" approach to opioids.

HANDS-ON APPROACH Most providers are embracing a multimodal approach that reduces, but doesn't necessarily eliminate, opioid use.

One disconnect
In many, if not most, regards, anesthesia providers and surgeons appear to be on the same page regarding post-op pain, but our survey reveals one notable exception. Surgeons were much more likely (38% vs. 9%) to favor opioid-based combination agents, such as Percocet and Vicodin; anesthesia providers were much more likely (44% vs. 14%) to lean toward full-scale multimodal approaches involving pre- and post-operative acetaminophen, NSAIDs and gabapentinoids.

"Surgeons have used combination agents for years and some are sticking to it," says Dr. Viscusi, who sounds a siren note of caution about the practice. "But combination agents tie your hands so you can't do around-the-clock acetaminophen. You don't want to have a patient on Percocet or Vicodin and then give them additional acetaminophen, because of concerns about liver toxicity. Instead, it might be worth thinking about doing your non-opioid as a standing around-the-clock medication and using a pure oral opioid as rescue."

Regional raves
Meanwhile, regional anesthesia continues its impressive advance among all providers, with more than 85% of respondents saying they prefer to do cases with regional anesthesia whenever possible and/or that they routinely employ regional and send patients home with continuous catheters and elastomeric pumps.

That's more good news for those battling to reduce reliance on opioids. "People seem to accept now that regional techniques really produce excellent analgesia," says Dr. Viscusi, "and they're using them as the cornerstone of their analgesic and anesthetic approach."

"Regional anesthesia and a multimodal approach should be the standard of care," says a Florida anesthesiologist who counts himself among those who consider opioids a last resort.

A strong regional program can also have other benefits, adds Jaime Baratta, MD, director of regional anesthesia at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia. "Regional anesthesia coupled with opioid reduction and multimodal analgesia improves throughput in the ambulatory setting by improving pain control and reducing opioid side effects," she says.

On the other side is a small minority (4%) who say regional is too burdensome, or that other obstacles stand in their way. "I used to use the post-op catheters and pumps, but insurance is rarely covering the costs," says Larry S. Goldstein, DPM, medical director or Riverside Surgical Center in Macon, Ga.

A Washington, D.C., surgeon ticks off a list of hurdles: "We have no induction room, monitoring, or assistant staff to provide regional anesthesia efficiently and without slowing down the OR schedule."

But among those who say they don't regularly rely on regional, most say they prefer infiltration, representing another move away from opioids.

READER SURVEY
How Do You Manage Post-op Pain?

We asked a panel of anesthesia providers and surgeons how they're managing post-op pain. Here's a summary of their responses.

In regard to opioids, which statement most accurately reflects your attitude?

• They're still the best way to manage pain, and when called for, they're my first choice. 9.2%
• I'm open to reducing opioid use, but I don't hesitate to use them when patients face real pain. 42.6%
• I'm actively trying to reduce opioid use by my patients, but they still have a role to play in mitigating pain. 38.9%
• I consider opioids only as a last resort. 9.2%

My usual approach to post-operative pain is _______ .

• a combination agent (Percocet or Vicodin, for example) 25.0%
• I routinely instruct patients to take acetaminophen and an NSAID around the clock and use opioids only as needed. 26.9%
• I routinely pre-treat patients with some analgesics before surgery. 21.2%
• When possible, I give pre-operative and post-operative acetaminophen, NSAIDs and a gabapentinoid drug. 26.9%

With regard to regional anesthesia/local anesthesia _______ .

• I prefer to do our cases under regional anesthesia whenever possible. 67.9%
• I routinely employ regional anesthesia and send patients home with continuous catheters and elastomeric pumps. 17.0%
• I find regional anesthesia too burdensome. 3.8%
• I prefer infiltration of local anesthetics to peripheral blocks. 11.3%

With respect to local anesthetic infiltration _______ .

• I use standard bupivacaine 80.0%
• I use Exparel for infiltration 10.0%
• I prefer to place a catheter in the wound and send the patient home with an elastomeric pump. 10.0%

I routinely employ these techniques in my ambulatory patients (respondents could choose ?more than one answer):

• spinal 32.1%
• epidural 18.9%
• peripheral blocks 90.6%
• TAP blocks 32.1%
• paravertebral blocks 17.0%
• infiltration 84.9%

Regarding nausea, _______ .

• I routinely give "triple therapy" (scopolamine, ondansetron and dexamethasone) to every patient to prevent PONV. 33.3%
• I screen for risk of PONV and treat only those at risk. 25.4%
• I routinely give dexamethasone during the anesthetic. 23.5%
• I use only ondansetron. 5.9%
• I take a "wait and see" approach. 11.8%

Source: Outpatient Surgery Magazine online survey InstaPoll, January 2016, n=55

Infiltrating the market
In fact, peripheral blocks (91% of respondents) and infiltration (86%) are both hugely popular choices among all respondents.

Delving deeper, those who use infiltration are overwhelmingly opting for standard bupivacaine (80%), rather than the considerably more expensive liposomal version.

"I used Exparel on many patients and had minimal success," says Dr. Goldstein.

"I tried to get Exparel in the facilities I'm on staff at, but no one wanted to pay for it," says Dr. Blank. "Now, with recent literature showing that it's not what it purports to be, I don't try anymore."

Still, 10% of respondents say they're sold on the benefits of Exparel. Meanwhile, another 10% say they prefer to implant catheters and send patients home with pain pumps.

SOUND THE ALARM Some providers may still be prescribing extended-release opioid products for acute pain, despite their having been linked to respiratory deaths.

Good news, bad news
Non-opioid intravenous analgesics are also popular choices for treating "routine post-operative pain," though a significant percentage of respondents complain that they can be prohibitively expensive.

Among those willing to pay the price, IV-acetaminophen (Ofirmev) is clearly the first choice (75.6%) among providers, though IV-ibuprofen (Caldolor, 19.5%) and IV-diclofenac (Dyloject, 9.8%) also have their advocates.

"That's more really good news," says Dr. Viscusi.

But it's tempered with bad news. Seventeen percent of respondents, mostly surgeons, say they also sometimes opt for extended-release opioid products like OxyContin and fentanyl patches. "That scares me," says Dr. Viscusi. "Extended-release opioids should not be used in new and acute pain. It's against the label. The label changed in 2013 because using them in the perioperative scenario was linked to respiratory deaths."

GENERAL AVOIDANCE The vast majority of survey respondents say they prefer to use regional anesthesia whenever possible.

Difficult patients
Another concern for Dr. Viscusi: Nearly 35% of respondents say they escalate opioid doses to account for tolerance when dealing with patients who are taking chronic opioid therapy or who have histories of substance abuse. "That could increase the risk of respiratory depression," he says. "I'd much rather see people use a multimodal approach, use regional and try not to escalate opioid doses."

Ketamine is also a popular choice (46.9%) for this subset of patients, as is deferring to the patient's regular prescriber (46.9%). Some providers say they do both, depending on the patient. "This requires a specific patient to discuss accurately," says William Landess, CRNA, MS, JD, corporate director of anesthesia at Palmetto Health in Columbia, S.C., "as there is no one cookie cutter approach to this difficult patient population."

Relatively few, meanwhile, routinely check urine drug screens pre-operatively (12.2%) or screen for substance abuse and refuse to do outpatient procedures on those who fail (10.2%).

Planning for nausea
Another impressive step forward: Providers are being proactive and preemptive regarding nausea, with only 12% saying they take a "wait-and-see" approach.

The vast majority either routinely give "triple therapy" (scopolamine, ondansetron and dexamethasone) to every patient (33.3%), screen for PONV risk and treat those at risk (25.4%), routinely give dexamethasone during the anesthetic (23.5%) or administer ondansetron (5.9%).

Major progress
The opioid message is being heard, says Dr. Viscusi, pointing to results that generally stand in stark contrast to what might have been expected 15, 10 or even 5 years ago.

"People appear to be embracing the idea of giving multiple non-opioids," he says. "And they're reaching into the more novel areas, like ketamine and lidocaine infusion. We're getting there, especially when it comes to embracing the idea that non-opioids have a role in post-operative pain. The next step is to extend the multimodal arsenal to pre-treatment. That should be the goal for those who put a lot of effort into their pain protocols and want to have well-honed recovery pathways." OSM