All of this makes good sense, especially as patients often have no idea what to expect after an operation, and it’s no surprise that its effectiveness in reducing opiate usage is beginning to show through in some small-scale studies.4
By no means should our concern for preventing opiate abuse wane once we get to the operating room. In reality, the intra- and postoperative pain control decisions surgeons and anesthesiologists make can have a profound effect on a patient’s later opiate requirements. Multimodal approaches using manageable doses of several different medications, with the hope of minimizing opiate use, or avoiding it altogether, have been met with some success and should certainly be part of our arsenal.5
This is particularly true with patients who are at higher risk for postoperative opiate abuse, such as those who have struggled with opiate addiction in the past. There’s a temptation, on the part of both physician and patient, to avoid opioids altogether in these patients, but whatever trials and tribulations these patients may have previously endured, we can’t lose sight of the fact that they just underwent an invasive procedure; their pain is real and needs to be treated.6
Interactions with these sorts of patients underscore the necessity and value of working closely with our colleagues in other specialties. We don’t hesitate to call for consults from cardiologists or endocrinologists or whatever other specialists might be able to shed some light on the safest way to manage our patients, so why shouldn’t we be just as willing to refer our patients, even preoperatively if need be, to the pain management service?
And similarly, are we sufficiently involving our colleagues in social work to ensure at-risk patients get the help they need, both during and subsequent to hospitalization, to avoid catastrophic results? Teamwork, I’m told, makes the dream work.
Communication is critical, but it might not be realistic to have a seasoned pain management specialist hold my hand every time I’m worried about prescribing too much Percocet. Instead, carefully constructed hospital-wide protocols can be useful in ensuring we avoid deleterious prescription of pain pills. These protocols don’t have to restrict our autonomy in any meaningful way; they could be valuable simply by nudging us toward prescribing smaller doses and reminding us to think carefully when we write larger ones.
Sad, as it sounds, it might also be beneficial to have a periodic reminder of the effects of our actions. It really shouldn’t take a jarring New Yorker piece to make the opioid epidemic, or my role in it, real. But for me, it did. I wonder whether, if I had better access to, or just more ardently pursued, information about my patients’ postoperative opioid use, my prescribing habits might organically become more thoughtful and conservative. I really don’t know. What I do know is that we have a responsibility to face up to this problem.
So, pop quiz: What are we going to do about it?
- Phillips D. Long-term opioid use major risk after surgery. Medscape Medical News. http://www.medscape.com/viewarticle/878531. April 12, 2017. Accessed July 12, 2017.
- Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821-826. doi: 10.1001/jamapsychiatry.2014.366
- Talbot M. The addicts next door. The New Yorker. http://www.newyorker.com/magazine/2017/06/05/the-addicts-next-door. Updated June 18, 2017. Accessed July 12, 2017.
- Burling S. Here’s something that curbs opioid use: pre-surgical counseling. Philly. http://www.philly.com/philly/health/addiction/Heres-something-that-curbs-opioid-use-pre-surgical-counseling-Rothman.html. Updated March 31, 2017. Accessed July 12, 2017.
- Burling S. How doctors are reducing opioid use after surgery. Philly. http://www.philly.com/philly/health/addiction/How-doctors-are-reducing-opioid-use-after-surgery.html. Updated March 31, 2017. Accessed July 12, 2017.
- LeMoult C. How do former opioid addicts safely get pain relief after surgery? NPR. http://www.npr.org/sections/health-shots/2017/04/20/519481712/how-do-former-opioid-addicts-safely-get-pain-relief-after-surgery. Updated April 20, 2017. Accessed July 12, 2017.