The United States has been grappling with a growing opioid epidemic that is forcing doctors, policymakers and patients to come up with alternative ways to manage both chronic and acute pain and reduce the amount of opioid prescribing in the country. A pair of studies presented recently at the 2018 meeting of the American Association of Orthopaedic Surgeons (AAOS) in New Orleans examine two possibilities for patients undergoing surgery.
The first study found that counseling before surgery significantly cuts the number of opioids patients take after hand surgery. And the second study, led by the same doctor, showed that ibuprofen and acetaminophen each treats postsurgical pain from hand surgery as well as oxycodone.
Asif Ilyas, MD, an orthopedic surgeon specializing in hand surgery at the Rothman Institute in Philadelphia, says he and his colleagues undertook the studies in an effort to challenge conventional wisdom that everybody should get opioids after an operation.
“If you have surgery, you have to get opioids. That’s the dogma. Whether you have your spine fused or a little cyst drained, you get Percocet,” he says.
But that’s not the case in the rest of the world, he adds. In Europe and Asia opioids are tightly regulated, with limitations on how much doctors can prescribe and insurers pay.
As a result, patients in most countries get little or no opioid medication, even after major orthopedic surgeries like ankle fracture fixation, according to David Ring, MD, a hand surgeon and associate dean for comprehensive care in the Dell Medical School at The University of Texas at Austin. “Yet their pain level and satisfaction with pain relief is as good or better than ours,” he says.
The story of America’s dependence on addictive painkillers is complex. It starts with aggressive marketing of opioids by pharmaceutical companies. “Once we were in the opioid-centric pain model, we had opioids for everything, including minor hand surgery,” Dr. Ring says. “The large number of pills led to large numbers of people with dependence and misuse disorders.”
Dr. Ring, who chairs the AAOS Patient Safety Committee, wasn’t involved in Dr. Ilyas’ studies, but he and Dr. Ilyas are on the same page when it comes to opioid overprescribing after surgery.
“Dr. Ilyas and colleagues are doing their part to atone for the role that orthopedic surgeons played in creating the current opioid epidemic,” Dr. Ring says.
For Dr. Ilyas, “atonement” has taken two forms. One is an opioid handout that he developed and reviewed with certain patients before they had carpal tunnel surgery. Those patients were compared to a control group that didn’t get opioid counseling.
Dr. Ilyas says the handout included facts and figures on the opioid crisis, the risks and benefits of the drugs and how to take them safely when prescribed. The underlying premise was that patients who knew more about opioids would take fewer pills and stop them sooner than patients who knew less. But the results surprised even him.
The day of surgery, the patients who got counseling took 0.65 opioid pills compared with 1.90 in the control group, with no differences in pain scores. On the first postsurgical day, there was again a significant difference in the number of pills used – 0.45 versus 1.50. By the end of the study, the counseled patients had taken 1.40 opioid doses compared with 4.20 in the control group – two-thirds fewer.
“We told them to start with ice and Tylenol [acetaminophen], and if that didn’t work, to try opioids at a very low dose and build up, if needed. And that had a very deliberate, positive effect,” Dr. Ilyas says.
In the real world, doctors don’t have time to counsel every surgical patient about opioids, so Dr. Ilyas created a 10-minute video that patients are required to watch.
“Doctors need to find some mechanism within their practice to educate patients on opioids,” he says.
Comparing Pain Meds
Dr. Ilyas also helped conduct a randomized, controlled, double-blind study that compared three common pain relievers – acetaminophen, ibuprofen and oxycodone.
The 30 patients in the study received one of the following: 10 capsules of 500 mg acetaminophen, 600 mg ibuprofen or 5 mg oxycodone (the three pills looked the same). They were followed for five days after carpal tunnel or trigger finger surgery. Because it was “double-blind,” neither patient nor surgeon knew which pain reliever a patient received.
The total number of pills taken was 0.5, 0.9 and 0.6, respectively. On a 0 to 10 scale, the worst pain experienced was 1.4 for the acetaminophen group, 1.5 for the ibuprofen group and 1.6 for the oxycodone patients. In other words, there was no difference in the number of pills taken or the amount of pain patients had. There was also no difference in adverse events.
“The study findings suggest that there is validity to using non-opioids instead of opioids after hand surgery,” Dr. Ilyas says. “And I would challenge my peers to try to customize prescribing to the procedure. Not everybody needs 40 oxycodone pills. You prescribe to the average patient, not the outliers. Most people need five, [so] prescribe five. And if it’s a smaller procedure, don’t prescribe any.”
Dr. Ring points out that the average number of pills taken in each group was less than one, “which means a notable percentage of patients took no pills to alleviate pain. And very low average scores for pain at its worst, which is remarkable. That means opioids are not useful after carpal tunnel and trigger finger release [surgeries].”
Simply having confidence that everything is OK and you just need some time to heal can help ease pain, says Dr. Ring. “The more opioids a person takes after an operation, the more pain they experience. It’s not likely the opioids are causing pain. Rather, people are [using opioids] to chase away the feeling that something is wrong, and that turns out to be an ineffective strategy. Music, funny movies, spending time with friends – these are some of the most effective ways to alleviate pain.”
Author: Linda Rath
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