Momentum Growing for Opioid-Free Surgery

Inside the alternative intra- and post-op pain management approaches that have a major impact on outcomes, safety and satisfaction.

The relationship between opioid use during and after surgery and the opioid addiction crisis is a complex one. While ineffective pain management can make recovery a nightmare, there’s a real risk for many patients when it comes to opioid addiction.

Combine the potential for abuse with adverse side effects like constipation, nausea and vomiting, and we’re seeing a growing percentage of patients who are asking their providers to forgo, or at least greatly reduce, opioids during and after surgery. Increasingly, surgeons and anesthesiologists are finding ways to do just that.

Inside the numbers

The opioid crisis has been the greatest driver of the push to move away from narcotic-heavy surgical care — and rightly so, considering the data. Approximately 130 people die in the U.S. each day as the result of an opioid overdose and of those deaths, nearly 40 percent are the result of prescription opioids. 

In 2020 alone, the CDC reported that 75 percent of all reported drug overdoses in the U.S. involved an opioid of some kind. That’s three in every four drug-related deaths. The renewed look at addiction risk in recent years has inspired some medical professionals to rethink how they handle anesthetics and post-surgery pain management with the goal of long-term patient health. “Historically, it wasn’t uncommon to see U.S. physicians send patients home with a 30-day supply of opioid medication after surgery,” says Shalini Shah, MD, director of pain services at UCI Health in Irvine, Calif. But today there’s far more research available suggesting that unleashing such powerful pain meds on patients without proper follow-up and monitoring can cause a lot more harm than good.

At UCI Health, for example, surgeons have been working to reduce the use of popularly prescribed opioids like hydrocodone, morphine, oxycodone and hydromorphone, while still controlling pain during and after procedures, something many patients truly appreciate. “When given a choice, we are seeing patients declining opioids more than in the past,” says Dr. Shah, adding that many patients find relief with anti-inflammatory and neuropathic medications that produce far fewer side effects.

A study in the Journal of the American College Surgeons seems to support this idea, suggesting that patients who underwent a pain management course were able to better regulate pain after minor surgical procedures without resorting to opioids.

“We see patients who are anxious about post-operative pain or are already on pain medications,” says Dr. Shah. “I’m often surprised to hear patients who have been on painkillers for several years express gratitude because no one has ever taken time to explain the risks and benefits to them.”

Multipronged approach to pain

Research into non-habit-forming alternatives to opioids for pain relief suggests that combined methods often yield the best results when it comes to patient satisfaction. For example, a recent study published in the journal Science found that drugs such as dexmedetomidine that bind to the norepinephrine adrenergic receptors are effective analgesics.

“We are interested in the use of this and related molecules to manage chronic pain,” explains the study’s author, Allan Basbaum, MD, a professor at the University of California in San Francisco. There are already a variety of non-opioid drugs used in surgical settings. Alternatives like anti-inflammatories, nerve medications, muscle relaxants, nerve blocks and catheters have all been effective in reducing pain, along with more holistic approaches like acupuncture and mindful meditation.

PAIN BLOCKADE Cannon E. Turner, MD, was recruited by Knoxville Orthopaedic for his use of ultrasound-guided nerve blocks and innovative anesthesia practices at same-day total joints centers.  |  Knoxville Orthopaedic Clinic

Benefits of opioid-free anesthesia

Anesthesiologists are also rethinking the use of narcotics during in surgery. While research is still fairly limited on the potential risks and benefits, advocacy groups like the Society for Opioid Free Anesthesia (SOFA) have been researching and promoting opioid-free pain management for a variety of surgeries.

Some of the benefits to opioid-free anesthesia, according to SOFA, include:

• non-addictive postoperative pain control; 
• protection against surgical and opioid-induced hyperalgesia;
• minimizing respiratory depression; 
• treating heroin and opioid addicts who are in recovery; 
• reducing the risk of cancer reoccurrence; 
• minimizing postoperative cognitive dysfunction, and 
• avoiding side effects like nausea, vomiting, sleep disturbance, hallucinations and cognitive dysfunction.

There’s also some encouraging research outside of the U.S. For instance, a 2021 study in Sweden looked at how opioid-free anesthesia can improve postoperative outcomes. The study concluded that there’s no evidence of adverse effects on patient safety and pain management in the research group, which consisted of patients who had a range of procedures, including laparoscopic, gastrointestinal and breast surgery. A separate study also touts the powerful non-opioid analgesics that are currently available and can sometimes have more favorable side effects and lower potential for developing addiction. Alternative cited medications included dexmedetomidine, intravenous acetaminophen, lidocaine and ketorolac, as well as ketamine, gabapentin and magnesium.

A health system’s new approach

Back in the states, the Mayo Clinic Health System in Red Wing, Minn., is interested in building opioid-free pain management throughout the surgical process. In addition to concerns about potential addiction, surgeons find while opioids do, indeed, work for limited periods of time to treat acute pain, they can eventually worsen pain stimulating nerve cells. It’s a phenomenon called hyperalgesia, where people become more sensitive to pain after receiving opioids.

“We are trying to do surgeries without any opioids at all,” says Ryan Sportel, a CRNA at the clinic. Two opioid-free solutions being used include a pain pump, essentially a catheter that’s placed at the affected nerve site during surgery (it can be taken home and used three to six days after surgery to deliver medication to the painful area), and a long-acting anesthetic that can successfully block pain for up to 72 hours. 

Unlike opioids, there are no euphoric feelings associated with these options. The nerve blocks work by simply blocking the brain from feeling pain. Targeted nerve blocks, single-dose infiltration of local anesthetics and cryoanalgesia are all part of a new, multimodal care pathway that is helping patients recover after increasingly complex surgical procedures.

‘It shook me’

Scott A. Sigman, MD, chief medical officer and founder of OrthoLazer Orthopedic Laser Centers in North Chelmsford, Mass., is also the team physician at the University of Massachusetts at Lowell. In that role, Dr. Sigman spends a lot of time treating young athletes, some of whom have dreams of going pro. For years he has seen the impact of opioid addiction among young people who ended up in the OR simply because of sports injuries. “I experienced a very bad year at a local high school,” says Dr. Sigman. “Four high school seniors died of opioid overdoses. And it shook me.”

Since then, he has spent time working with patients who have experienced addiction, not only developing pain management options for them, but learning firsthand that it’s not about the patients. “Addiction is not a choice,” he said. The “wakeup call,” as he describes it, has led him to become an advocate for opioid alternatives in surgery.

“The operating room was an inadvertent gateway to opioid addiction, and we recognized that we can change that,” he says. Rather than immediately prescribing opioids to patients as was the norm a few years ago, he now likes to consider alternatives that would deliver 72 hours’ worth of relief without the risk of addiction. Knowing that pain management is integral to patient recovery, Dr. Sigman spent a few years having patients rate their satisfaction in terms of pain relief, and soon discovered that alternatives to narcotics were actually working really well for a lot of people. “We created a revolutionary paradigm shift in the perioperative window,” he said. And now the CDC is even making recommendations for opioid-free surgical solutions (new guidelines were published in April 2022).

A few successful solutions Dr. Sigman now uses are elongated anesthetics, intravenous non-steroidal inflammatories and regional blocks that can last as long as three days. Other alternatives include nerve stimulators, massage and laser therapy, and acupuncture. There’s also a new neuro-modulation device currently going through FDA approval that can be operated through a smartphone app that can calm nerves for weeks.

“The last thing that we want to do is take a patient with a chronic orthopedic condition and expose them to opioids,” says Dr. Sigman, who touts patient communication and education from day one as a vital part of the process. “We start talking to patients about this on the first visit,” he says, explaining the alternatives to pain relief that can help avoid potential addiction. “It’s important that the conversation continues throughout the entire cycle of care.”

Many of his patients have been eager to go opioid-free. “Everyone knows someone,” he says, who has experienced addiction or worse. The research only reiterates the fears providers like Dr. Sigman have about introducing patients to particularly addictive substances without at least trying alternatives first.

An article by the CDC followed 100 patients who were prescribed opioids for 24 hours after surgery. As many as six of them were still taking the drugs after one year. “The power of addiction can happen very quickly,” said Dr. Sigman. “We want to minimize the exposure.”

Does this mean that he never wants opioids prescribed again? Absolutely not. “There are a lot of patients who function well with them, like cancer patients,” he says. “But we do have a responsibility to our patients to minimize the next wave of addiction.” OSM