Opioids Unnecessary After Surgery in Some Cases

Laird Harrison

March 07, 2018

NEW ORLEANS — After carpal tunnel or stenosing tenosynovitis release surgery, acetaminophen, ibuprofen, and oxycodone work equally well for pain relief, researchers report.

"It's become standard that if you have any procedure, you get opioids," said investigator Asif Ilyas, MD, from the Rothman Institute in Philadelphia. "We're trying to challenge that dogma."

"Orthopedic surgeons are one of the highest-volume prescribers of opioid medications," he told Medscape Medical News. "Our intentions are good, but there are a lot of unintended consequences."

Orthopedic surgeons are one of the highest-volume prescribers of opioid medications.

In fact, one study showed that about 6% of patients given opioids for the first time were still using them 90 days after a surgical procedure (JAMA Surg. 2017;152:e170504). Americans consume vastly more opioids per capita than people in the rest of the world, said Ilyas, and these drugs are now the leading cause of death among young people in the United States.

Counseling patients about the uses and abuses of opioids can also significantly reduce the use of these medications, according to a separate study, also presented by Ilyas here at the American Academy of Orthopaedic Surgeons (AAOS) 2018 Annual Meeting.

The findings suggest practical ways that orthopedists can reduce the risk that their patients and others will be harmed by the diversion and misuse of opioids.

To see whether other analgesics could be substituted for opioids, Ilyas and his colleagues randomly assigned 75 patients undergoing carpal tunnel release and 37 undergoing stenosing tenosynovitis release to 10 doses of one of three analgesics: oxycodone 5 mg, ibuprofen 600 mg, and acetaminophen 500 mg.

Ibuprofen and Acetaminophen vs Oxycodone

All 10 doses were provided in the form of unmarked opaque capsules, so patients were blinded to their treatment group.

Differences in the number of pills taken and requests for stronger pain relief were not significant for the three regimens. The only significant difference was on the first day after surgery, when patients in the oxycodone group reported slightly more pain.

Table. Pain Relief Outcomes 5 Days After Surgery

Outcome Acetaminophen, n Ibuprofen, n Oxycodone, n
Request for stronger pain relief 2 2 2
Mean number of pills consumed 3.1 4.4 2.9

 

Patients in the acetaminophen and ibuprofen groups were less likely than those in the oxycodone group to experience gastrointestinal adverse events (3% vs 3% vs 15%).

This study shows that "you don't have to have an opioid to manage patients' postoperative pain," Ilyas said.

Just educating patients significantly reduces postoperative opioid consumption.

In the second study, Ilyas and Todd Alter, also from the Rothman Institute, randomly assigned 40 patients undergoing carpal tunnel release to counseling about opioids or to no counseling.

Ilyas met one-on-one with each patient in the counseling group for about 5 minutes to discuss what opioids are, the risks and benefits, the opioid crisis, how many opioids are typically needed for this type of procedure, and other safe ways to manage pain.

On the day of surgery, patients who received counseling consumed fewer opioid pills than those who did not (0.65 vs 1.90). And patients who received counseling took fewer pills during the 3 days after surgery (1.4 vs 4.2; < .05).

Pain reported by the patients was not significantly different between the two groups. "Just educating patients significantly reduces postoperative opioid consumption," Ilyas said.

It is not necessary for physicians to do this type of counseling themselves, he pointed out. Allied health providers, such as nurses and physicians assistants, can do it. In his own practice, he has created a 10-minute video on opioids and other topics that patients watch before surgery. "I find that to be efficient," he reported.

I don't give more than five opioid pills — oxycodone or codeine — after these smaller surgeries.

After research showed that physicians in his practice were prescribing far more opioid pills than patients were consuming, he changed his practice and now only prescribes the average number of pills that patients use for a given procedure, rather than the maximum.

"I don't give more than five opioid pills — oxycodone or codeine — after these smaller surgeries," he said. And he tells patients they do not need to fill the prescription at all. "I encourage them to take a nonopioid instead."

One reason physicians give for prescribing larger numbers of opioids is the concern that patients will return to request refills. "Once we started educating patients, that has not been the case at all," said Ilyas. "We're not seeing an increase in phone calls."

The small number of pills that patients took in these two studies, especially in the counseling study — where some patients apparently took no pills at all — is striking, said David Ring, MD, from the University of Texas at Austin, who is chair of the AAOS quality and patient safety committee.

"I find that really compelling," he told Medscape Medical News.

In his own practice, Ring said he has stopped prescribing opioids for patients who undergo carpal tunnel and stenosing tenosynovitis release procedures.

The best pain relief is peace of mind.

Instead, he discusses pain strategies with his patients, starting by asking them what pain relief measures they used the last time they had surgery. If they didn't need any opioids, that makes it easy to avoid an opioid prescription for the new procedure. He gives patients his cell phone number and offers to write them an opioid prescription electronically if they need one. So far, he reported, only two patients have requested the opioids.

By making himself available, he shows patients that he cares, and that gives them a sense of control over their pain, said Ring. "The best pain relief is peace of mind."

If a patient used a lot of opioids after a previous surgery, that can open the door to a broader discussion about emotional needs and support systems.

"For so long, we and our patients have thought about orthopedics as just a mechanical thing — find the problem and do a little carpentry on it," he explained. "But now we're realizing that we have to treat the whole patient."

Ilyas reports financial relationships to DePuy, Johnson & Johnson, Globus Medical, and Jaypee Medical Publishers. Ring reports financial relationships with Skeletal Dynamics and Wright Medical Technology.

American Academy of Orthopaedic Surgeons (AAOS) 2018 Annual Meeting: Abstract P0219, presented March 6, 2018; Abstract P0725, to be presented March 8, 2018.

Follow Medscape Orthopedics on Twitter @MedscapeOrtho and Laird Harrison @LairdH

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