Can You Cut Opioid Use in Half?

You could make a legitimate argument that the CDC’s labeling of pain as “the fifth vital sign” in 2001 did more harm than good and directly contributed to the current opioid crisis, a problem deeply rooted in physicians’ attempts to completely eliminate pain with unnecessary or unnecessarily large painkiller prescriptions.

“Opioids themselves aren’t the problem,” says Charles Luke, MD, MBA, FASAM, director of acute interventional perioperative pain and regional anesthesiology at the University of Pittsburgh (Pa.) Medical Center, where in recent years surgeons are writing 50% fewer opioid prescriptions. “The problem is that they’ve been overutilized for decades.”

Dr. Luke is board certified in anesthesia and addiction medicine, and fellowship trained in acute medicine and regional anesthesia. He’s seen and experienced it all in ORs, detox centers and outpatient rehab centers. “I don’t think opioids are bad,” he says. “They have a place in post-op pain management. We don’t need to eliminate opioids, but we do need to reduce the amount used.”

About 60% of surgeries performed in the United States are done in outpatient facilities, according to Dr. Luke, who says that percentage will only increase. He calls for surgical professionals to standardize pain management protocols to make sure opioids are used as sparingly as possible.

Dr. Luke has been active in slashing by half the amount of opioids surgeons prescribe at UPMC. “That’s where we needed to get to immediately,” he says. “But there’s still more work to do.”

The clinical team at Keck School of Medicine at the University of Southern California in Los Angeles has also made it their mission to reduce opioid prescription rates and manage surgical pain through non-opioid alternatives. They implemented an enhanced recovery program with thoracic surgery about 18 months ago and have since added 10 service lines to the list. To date, they’ve decreased opioid use per service line by an average of 60%. Their efforts, like those at UPMC, focus on quality patient education, a reliance on regional anesthesia and an effective mix of non-opioid pain relievers.

The ultimate success of any opioid-reducing program is directly linked to quality patient education. On the day of surgery, anesthesia providers at Keck School of Medicine have very frank discussions with patients about how they can expect to feel after surgery.

“We make it clear that they will have some pain, and outline what analgesia and anesthesia they’ll be getting and why,” says Shane C. Dickerson, MD, the director of outpatient anesthesia services and an assistant clinical professor of anesthesiology at Keck School of Medicine. “We use statistics to drive home why we go above and beyond to avoid unnecessary opioid usage.”

For example, they tell patients, “We’re using an opioid-sparing protocol because the literature shows there’s a 6% to 8% chance you could get hooked on opioids down the line, and we’re going to do everything in our power to prevent that from happening.”

Patients who are scheduled for surgery at UPMC are evaluated to determine how to optimize them for surgery and map out perioperative and post-operative pain management plans. “Setting reasonable expectations goes a long way to improving how patients react to pain,” says Dr. Luke. “You need to set expectations that patients will feel some pain, even minor discomfort, as early as possible.”

Dr. Luke champions opioid-free anesthesia and strongly urges the use of regional anesthesia — he calls it the cornerstone of UPMC’s perioperative pain management program — whenever it’s deemed appropriate.

Nerve blocks can function as the primary anesthetic absent any opioids, says Michael Kim, MD, medical director of the value improvement office and clinical assistant professor of anesthesiology at Keck School of Medicine. Anesthesia providers there routinely administer retrobulbar, superficial cervical plexus and sphenopalatine blocks for surgeries involving the head and neck. They rely on the “big 5” — interscalene, supraclavicular, femoral, popliteal and adductor canal nerve blocks — to provide analgesia for the majority of patients who undergo orthopedic procedures.

As an adjunct to nerve blocks, the right multimodal cocktail is invaluable in curbing post-op opioid usage. “Each patient gets 1g of PO Tylenol to start,” says Dr. Dickerson. “They also get celecoxib or intraoperative ketorolac, with or without gabapentinoids, which have been shown to reduce opioid requirements and aid in preventing chronic post-surgical pain.

“We also employ a multimodal general anesthetic in the OR, which includes NMDA antagonists like magnesium and ketamine, and anti-inflammatories like lidocaine and dexamethasone, all of which have been shown to reduce the amount of opioids used to manage postoperative pain,” adds Dr. Dickerson.

Surgeons sometimes hesitate to have regional blocks placed on their patients, says Dr. Luke. “But that attitude is changing,” he adds, “because of the data we’ve accumulated over many years and the number of surgeries we’ve performed with regional that have slashed rates of opioid dependence that can develop even after 4 or 5 days of use.”

Multimodal pain medications — acetaminophen, NSAIDs, alpha-2 antagonists, gabapentinoids and ketamine are commonly used — keep pain at bay when nerve blocks wear off. “Medications that were not being used in the past are now being used routinely,” says Dr. Luke.