August 27th, 2017

Surgery Without Opioids

[Editor’s Note: Stable recovery from alcoholism or opioid addiction can be disrupted by exposure to opioid medication during a surgical procedure. Fortunately, safer alternatives for surgical pain management are now available. Here is the description of an approach that was developed by Dr. Joseph Myers, an anesthesiologist at MedStar Georgetown University Medical Center.]

ComfortCare: Guiding Recovering Patients Safely Through Surgery

Current reporting on the opioid crisis often tells the story of a person in recovery who requires surgery and is administered opioids—sometimes against their wishes. The result has become all too familiar: a new reliance on opioids, followed by relapse and eventual heroin overdose. Often called “the largest unrecognized contributors to the opioid problem,” anesthesiologists traditionally administer opioids on the way to the operating room, during the anesthetic, and in the recovery room.

Today, however, numerous non-opioid, non-addictive, pain medications are readily available. Though still underutilized, these non-narcotic options have dramatically changed the analgesic playing field over the past ten years. This new multimodal analgesia approach is strongly recommended in the Guidelines on the Management of Postoperative Pain, which states “systemic opioids may not be required in all surgical patients.”

A multimodal pain strategy is one that uses combinations of medications and methods to combat pain and reduce opioid use. Choices are made based on a lack of adverse effects and the ability to provide additional pain relief. For instance, acetaminophen (Tylenol) is newly available in an IV preparation that has a stronger effect than the over the counter pill while maintaining its safety profile. The nonsteroidal anti-inflammatory ketorolac (Toradol) has pain-relieving qualities equivalent to 8-12 mg of morphine — without the nausea, vomiting, constipation, and other opioid side effects.

Most useful is a local anesthetic – liposomal bupivacaine (Exparel). While other local anesthetics for last hours, Exparel lasts for days and has allowed patients requiring everything from wisdom tooth extraction to mastectomy and lower extremity amputation to awaken comfortably and remain so without opioids.  

The ComfortCare program, designed to safely guide recovering addicts through the surgical operations without relapse, is now being put into practice by anesthesiologists who emphasize patient-centered collaboration. When faced with the choice of surgical pain or addictive opioid medications, recovering patients are often conflicted and unprepared. Having the patient and physician working as a team can create a comprehensive non-opioid plan that is both safe and comfortable. Choosing the type of anesthesia, as well as medications like the three described above, is always part of the planning.

Other options can strengthen the multimodal strategy for addressing pain: acupuncture, therapeutic music, prayer, meditation, and utilization of a supportive caregiver address the full range of physical, emotional, spiritual, and environmental influences affecting a person’s health and recovery. Dr. Myers tells his patients, “The goal is to move toward an opioid-free home environment with surgery behind you and a bright future ahead.”

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