Managing Pain Without Opioids


Narcotics aren't needed to send patients home in comfort after painful procedures.

Surgical professionals are growing more interested in finding ways to eliminate opioids from the post-op pain management equation and the stakes have never been higher. The national opioid overdose crisis has only worsened during the pandemic, creating a sense of urgency among physicians to find alternative ways to help their patients rest easy after surgery without exposing them to powerful painkillers that could lead to overuse or addiction.

Opioids have multiple risks in the perioperative setting beyond the dangers of dependence, including respiratory depression, nausea, vomiting, constipation and altered mental status, which can complicate recovery or prolong inpatient admission, says Jennifer Goins, MD, an anesthesiologist at the Mayo Clinic in Austin, Minn. “In addition to the acute effects, opioid exposure carries the risk of addiction and dependence, which has been seen at increased frequency with higher doses and prolonged use postoperatively.”

A team of physicians at Henry Ford Health System in Detroit assessed the effectiveness of using opioid alternatives to treat post-op pain. Their recent study, published in the journal Arthroscopy, involved 61 patients who underwent ACL repair with 30 receiving opioids for pain control and 31 receiving a non-opioid regimen involving the use of anti-inflammatories, acetaminophen and muscle relaxers.

Each study participant underwent the same pre-op and intraoperative protocol, which included receiving an adductor canal nerve block to anesthetize the medial portion of the knee. After surgery, half of the patients received oxycodone with instructions to take it as necessary to treat breakthrough pain, while the other patients were on a strict pain control protocol consisting of the anti-inflammatory ketorolac dosed twice daily and gabapentin and diazepam, each dosed three times daily. The risks of side effects associated with ketorolac use increase after more than five days of use, so its administration was limited to the first five days post-op. Patients were then switched to meloxicam to finish out the regimen.

“These medications create a synergistic effect in the patient’s body to decrease pain,” says Vasilios (Bill) Moutzouros, MD, co-author of the study and an orthopedic surgeon and chief of sports medicine at Henry Ford Health. “The entire protocol lasts 14 days, but most patients wean off the medications seven to 10 days after their pain has subsided.” 

Pain scores in the non-opioid group were equivalent to those in the opioid group, and there were no significant differences in side effects among the patients. “The surprise was how effective the non-opioid regimen was,” says Dr. Moutzouros. “It was at times more effective than using opioids, probably because it was working on nerve pain, muscle spasms and general inflammation in a very precise fashion. By being more specific with how you target pain, you can get similar, and sometimes even better, outcomes than if you use opioids.”

Dr. Moutzouros notes that the non-opioid protocol was better at treating issues such as muscle spasms in the quadriceps and hamstrings that can occur after ACL repair.

His research team began planning the study several years ago to determine if there was a way to cut down on the amount of opioids they used after surgery because even a small amount can lead to overuse. “We’ve since shown that not only can we limit opioid usage,” he says, “but there are patients who don’t need opioids at all if alternative pathways are used to manage their pain.”

Dr. Goins points to the importance of administering anti-inflammatories preoperatively or using regional anesthesia during procedures to help keep patients comfortable in the postoperative period. “Anesthesia providers working extremity surgeries are often able to use regional anesthesia, local anesthetics or continuous nerve blocks to help patients through the most painful first day or two after surgery,” she says. “Similar techniques can also be utilized for intra-abdominal and intrathoracic surgeries, although the techniques are more difficult to implement and provide less complete relief.”

Personalized approach

COMPASSIONATE CARE Dr. Luke Elms informs a patient about the benefits of his non-opioid post-op pain management protocol that relies on the targeted use of over-the-counter analgesics.  |  Orlando Health

Medications used as part of a multimodal pain management plan must be prescribed based on the specific needs of individual patients and precisely timed, meaning patient education is a key component of any non-opioid pain protocol program, says Dr. Moutzouros. He suggests discharging patients with a dosing grid that breaks down their post-op treatment protocol day by day and hour by hour, so they know exactly which medications to take and when to take them.

The grid can include a gradual reduction in the dosing of the medications to help patients wean themselves off the treatments, if possible, after about five days. Give the grid to patients and their family members before scheduled procedures and explain each step of the dosing regimen as well as the importance of timing the medications correctly. This way, they’ll have a chance to digest the information and ask questions before they arrive for surgery.

“It’s easy to give a single medication and tell patients to use it as needed instead of four different therapies that need to be scheduled and timed appropriately,” says Dr. Moutzouros. “Multimodal medication regimens are more intensive, but they’re worth implementing in order to not expose patients to opioids unnecessarily.”

It’s also crucial to consider how to best treat patients who regularly take opioids to treat chronic pain and often have a harder time dealing with discomfort in the postoperative setting, according to Dr. Goins. “For this patient population, it’s recommended to decrease or eliminate the use of daily opioid medications prior to elective surgery,” she says. “Chronic opioid use is known to amplify pain signals. Minimizing this effect preoperatively will decrease the need for opioids postoperatively.”

Dr. Goins points to the importance of involving all members of a patient’s care team — primary care physician, surgeon, anesthesiologist, pain specialist — in creating a pain management plan for the perioperative period as well as contingency plans for emergent needs. These coordinated efforts often eliminate worry and frustration for both patients and providers.

Patients like having a non-opioid pain management protocol as an option in their care plan. “We’ve found that many patients or their caregivers sought out the non-opioid protocol to avoid the side effects and risks associated with narcotics when they found out it was an option,” says Dr. Moutzouros.

Because non-opioid pain management has the potential to improve outcomes and increase patient satisfaction, many other specialties are looking to it as an option to keep patients pain-free and happy. “All surgeries are potentially amenable to reduced doses or no opioid use postoperatively, depending on the surgical technique, use of regional anesthesia, the ability to maximize non-opioid medications and the individual patient’s underlying medical conditions,” says Dr. Goins. “Balancing all these factors helps us create an optimal pain management plan that’s tailored to each patient.”

Orlando Health, a hospital system in Central Florida, recently conducted a national survery that found 80% of respondents believe opioids are needed to manage post-op pain. Although 65% of the respondents were more worried about managing their post-op pain than the risk of becoming addicted to opioids, 68% said they would be interested in trying alternative opioid-free therapies.

“When I talk to patients and reassure them that we’re going to be replacing opioids with a much more effective and safe method, and talk to them about the risks of opioids that have become much more evident with the research that’s come out recently, most patients are very open to the idea,” says Luke Elms, MD, a general surgeon at Orlando Health Dr. P. Phillips Hospital.

He has developed a non-opioid post-op pain management protocol based on the use of acetaminophen, ibuprofen and muscle relaxers, which he says in combination provide targeted and powerful pain relief.

“It’s very important to keep in mind that surgical patients do have pain and need pain control. The solution is not to pull opioids away and leave them to fend for themselves,” says Dr. Elms. “This is a real problem after surgery that needs to be addressed in a compassionate manner.” OSM

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