Cautious Opioid Use Needed in Pain Management Toolkit

Bridget Fahy, MD, FACS, and John A. Harvin, MD, MS, FACS, led a discussion on actionable strategy for pain management in the Town Hall session The Opioid Epidemic: Can I Still Treat Pain?

Taking opioids out of the pain management equation is not a realistic solution to the opioid crisis.

“The expectation that we’re going to get to zero opioids anytime soon is kind of a pipe dream. There’s just not enough drugs out there, and at some point, we run out of options and you have to use them,” said John A. Harvin, MD, MS, FACS, co-moderator of the Clinical Congress Town Hall session The Opioid Epidemic: Can I Still Treat Pain? A rational and reasonable approach is key to safe opioid prescribing, he advised.

Dr. Harvin is an associate professor of surgery in the division of acute care surgery at McGovern Medical School at The University of Texas Health Science Center at Houston. He and Bridget Fahy, MD, FACS, led a discussion on actionable pain management strategies for different patient populations and diseases. She is a professor of surgery in the divisions of surgical oncology and palliative medicine, the chief of surgical oncology, and the program director of the Complex General Surgical Oncology Fellowship at the University of New Mexico in Albuquerque.

The Town Hall moderators emphasized the importance of tailoring pain management to the individual, providing patient education, and setting expectations with the patient.

“We do need to be held accountable for what we’re prescribing and educating patients and their families about the side effects and so forth,” Dr. Fahy said, stressing the value of postoperative care plans and recommending the ACS Surgical Patient Education Program to help patients and caregivers understand the dynamics of safe and effective pain control following surgery for adults and children and teens.

Communication about the efficacy of non-opioid options, especially to patients who express an aversion to taking an opioid for pain management, is crucial. There is a limited number of non-opioid pharmacological adjuncts in the postoperative toolkit, each providing varying degrees of incremental pain relief, Dr. Harvin noted. “If they don’t work … then you’re going to have pain until the pain subsides,” he cautioned while recognizing that many pain regimens involve a multimodal approach.

The counterweight to the effective pain management achieved by opioids is the relatively quick escalation of the probability of opioid misuse once treatment with these agents begins. The risk of persistent opioid use, which is defined as greater than 30 or 60 days, increases dramatically after just 5 days of exposure, Dr. Fahy said.

“The goal is really to get the patients off of opioids after 5 days,” she continued. “And I think part of educating patients is also about that: ‘That’s why I’m pushing so hard to get you off of opioids, because we know that’s an important inflection point for when we have to be concerned that this could turn into longer-term opioid use.’”

Evidence-based guidelines from Michigan OPEN can help physicians determine what drug and in what quantity a patient should be prescribed for pain management as part of their postoperative or acute care. The site also offers information on the use of non-opioid agents, including acetaminophen and ibuprofen, as well as the role of non-pharmacological solutions such as nutrition, physical activity, and adequate sleep to promote healing following surgery.

Overprescribing opioids creates potential hazards beyond the patient who has unused pills. When a patient is prescribed narcotics, the risk of anyone in the family having an addiction to them goes up. “So, it’s not just about the individual patients,” Dr. Harvin said. “It’s about the diversion.”

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