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No one goes into the operating room believing they may come out dependent on powerful opioids. But as the anesthetic wears off in the hours after a hernia repair, a knee replacement, or some other surgical procedure — and the pain sets in — most patients are prescribed opioids.
Many can find themselves becoming reliant on opioids.
Each year, 90% of surgical patients are prescribed opioids for pain management and an estimated 2.6 million Americans become persistent users of OxyContin, Percocet, Vicodin, or other opioid drugs following initial exposure after surgery. More than 400,000 of those individuals then go on to become long-term users — fueling the nation’s deadly opioid crisis.
And the problem doesn’t stop with patients. Over one billion leftover or unused pills are often kept in unsecure locations, like medicine cabinets or closets, in homes across the U.S.1 One review published in JAMA Surgery found that anywhere from 42% to 71% of prescribed opioids ultimately go unused by the surgical patient. According to a journal article in Pharmacy and Clinical Pharmacology, postoperative opioid prescribing at hospital discharge exceeds published recommendations for common surgical procedures, which can be potentially accessible to others, increasing the risks of misuse.2
The surgical setting thus serves as an unintentional gateway to persistent opioid use, dependence, and addiction — both as a direct consequence of postoperative pain management and indirectly through the diversion of leftover pills. Simply, surgeons prescribe opioids with the intention of helping limit patients’ pain after surgery and patients take the medication, unaware of alternative options. Only by preventing unnecessary opioid usage after surgery can doctors and patients then reasonably decrease the potential for abuse and misuse.
Fortunately, a growing recognition of the problem is prompting many healthcare professionals and surgical patients to forgo opioids in favor of non-opioid alternative pain-relieving strategies. “There are novel extended-release dual-acting local anesthetics on the horizon that could revolutionize postoperative pain management,” said Dr. Roy Soto, director of the anesthesiology residency program for the Beaumont Health System in Michigan. “These new options are designed to deliver long-lasting postoperative pain management. Longer coverage in pain management will allow for fewer opioid pills to be dispensed while still effectively managing pain, which I believe could change the course of recovery for patients.”
Realistic expectations
Soto also emphasized the importance of education, both for healthcare professionals — so they’re aware of the ways in which postoperative opioids are perpetuating the current epidemic and recognize the availability of other options — and for patients to better manage their expectations for pain after surgery so they don’t reflexively reach for opioids.
“Many patients expect zero pain after surgery, and many expect opioids — and opioids alone — to treat any pain that might arise,” Soto said. “But it is very important to realize some amount of pain after surgery is normal.” And if patients can get through the first few days, ideally with the help of non-opioids, they can manage any lingering pain.
Non-opioid multimodal pain management that addresses a patient’s acute pain can often be all that a patient needs, Soto noted — and these non-opioid analgesics don’t carry the same concerns as opioids in terms of side effects and the potential for addiction. There are exceptions, and “opioids historically have had a place in pain management,” said Heron Therapeutics’ President and CEO Barry Quart. For some patients — and for some types of surgeries — opioids have always been an option that provides respite from severe pain. But, Quart stressed, “patients and physicians are limited by the current non-opioid options, which are not sufficiently effective to allow for opioid-free postoperative pain management in many patients.”
“It’s becoming more apparent that opioid discharge prescriptions for pain control after surgery is an important contributor to the opioid epidemic,” said Quart. “The task now for healthcare providers is to assess their postoperative pain management protocols to ensure appropriate pain control while reducing and possibly eliminating postoperative opioids, including discharge prescriptions, while allowing the patient to recuperate with acceptable levels of pain. There are new options on the horizon to help accomplish this change in protocol.”
For more information about a non-opioid, dual-acting local anesthetic alternative in development to treat postoperative pain, visit www.herontx.com.
1 Brummett, Chad M., et al. 2017. “New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults.” JAMA Surgery. 152(6): e170504. doi:10.1001/jamasurg.2017.0504.
2 Mikosz CA, Zhang K, Haegerich T, et al. Indication-Specific Opioid Prescribing for US Patients With Medicaid or Private Insurance, 2017. JAMA Netw Open. 2020;3(5):e204514. doi:10.1001/jamanetworkopen.2020.4514
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