The Overuse of Postoperative Narcotics


Healthy Living – October 9, 2017
Anthony Tannous, MD - Eastern Maine Medical Center
It is hard to imagine a day passing by without being reminded that we are in the midst of an opioid epidemic. This deadly problem may affect you on a personal level, affect a loved one or be merely one of a myriad of social issues that you hear or read about on the news. Either way, it is all too real and it is happening right here where we live. At the root of the problem are physicians’ prescription patterns. It is hard to believe that doctors such as myself, who have taken an oath to always help and never hurt, can unwillingly contribute to such a vicious and insidious problem that is crippling our communities.

Opioid over-prescribing peaked in 2010 and has decreased steadily since on a yearly basis but is very much still a major problem.  Medications such as oxycodone, fentanyl and morphine were responsible for nearly half of the 33,000 overdose deaths recorded in 2015, according to the Centers for Disease Control and Prevention. How did Americans get their hands on so many opioid pills? Studies suggest that surgical patients have plenty go to around.

I do not want to tackle narcotic prescription for chronic pain as it is altogether a separate problem. Instead I want to focus on the prescribing of opioids for acute pain such as the pain incurred after trauma or surgery. Our goal is for our patients to experience as minimal discomfort as possible after surgery and in the process we have overestimated their need for narcotic medications especially for routine surgeries. This goes in parallel with many patients’ expectation that their pain can only be dealt with by opioids such as oxycodone, hydrocodone or hydromorphone (dilaudid). Regulatory organisms have now limited our ability to overprescribe narcotics by only allowing the prescription of one week’s worth of opioid for acute pain at a time and the inability to refill that prescription until that duration expires. Rigorous prescription monitoring programs have also been established in many states including Maine to track over-prescription and overutilization.

 In many cases however, even one week of narcotics may not be warranted and there are many alternative strategies and non-opioid medications that can help with the management of pain after simple low intensity procedures such as appendectomy, cholecystectomy, hernia repairs, minor orthopedic surgery and other as well as low impact trauma such as falls and simple lacerations.

Multimodal analgesia is one of those strategies. It is based on the use of a combination of non-addictive medications to attack the pain pathways at different levels and result in optimal relief. Such medications include over the counter relatively low risk agents such as acetaminophen and ibuprofen which when used in combination and at alternative times can be opioid sparing for many procedures. It is important to check the maximum daily dose and make sure to not exceed it. Consulting with a pharmacist or a healthcare provider is always advised. Even when opioids are needed, using synergistic combinations of opioids with acetaminophen or ibuprofen for example can result in a much lower total dose of opioid needed.

For many more evolved procedures, it has been proven by many studies that starting a combination of non-opioid medication a few days before surgery builds up enough levels for an adequate post-operative opioid sparing pain relief regimen. It is always wise to check with your physician whether that is an option for you.

Another very important thing to check is whether you are a candidate for local or regional anesthesia. It may be possible for your surgeon to use local anesthetics in the surgical field to reduce your postoperative discomfort. Advances in anesthesia have also made it possible to manage pain after surgery with regional blocks and epidural locally infusing catheters that reduce the need for narcotics and result in quicker ambulation and mobilization and subsequently quicker discharges from the hospital. These modalities are not always possible but they should be offered and asked about.

We live in a society of instant gratification. There is an expectation for zero discomfort and doctors who wish to care for their patients want them to go through their procedures as smoothly as possible. But the reality is that by overlooking the alternatives and jumping to reflex opioid prescribing we are putting our patients at risk for immediate complications such as respiratory depression and difficult to manage constipation as well as more prolonged insidious ones such as addiction. It is everyone’s responsibility to not take these medications for granted and to use them judiciously as a last resort because fighting the opioid epidemic is everyone’s responsibility.