Surgery Patients Just as Satisfied With Opioid-Sparing Pain Treatment

By Linda Carroll

January 29, 2021

(Reuters Health) - Patients who received preoperative counseling along with prescriptions for acetaminophen, ibuprofen and a small number of opioid pills for the week following surgery reported less pain and similar satisfaction to those who received typical opioid prescriptions, a new study finds.

In the retrospective comparison of data from 310 patients who participated in an opioid-sparing pathway after surgery to 310 patients who received standard of care, researchers found that opioid use could be significantly cut back without raising pain scores or lowering patient satisfaction, the study team reports in JAMA Surgery.

"We are always looking for ways to protect patients from risks of opioids after surgery," said study coauthor Dr. Ryan Howard, a general surgical resident at the University of Michigan, Ann Arbor. "Our end goal is to prioritize non-opioid medications and even non-medication treatments, such as heating pads."

"What we've learned is that patients do quite well with very, very few opioids," Dr. Howard said. "Counseling is a massive, massive part of these efforts. We tell them to expect to feel a little pain. And it's OK if they can be functional and go to work and go about their daily life."

To look at how well the opioid sparing pathway stacked up against standard care, Dr. Howard and his colleagues compared the outcomes of opioid-naive patients participating in an opioid-sparing pathway after surgery with a propensity score-matched cohort of opioid-naive patients who received standard of care for the same procedures.

Patients included in the analysis had undergone laparoscopic cholecystectomy, hernia repair or thyroidectomy between August 1, 2018 and December 31, 2019.

The patients in the opioid sparing pathway received preoperative counseling to use acetaminophen and ibuprofen for one week after surgery. Postoperatively they received prescriptions for these medications and a small prescription of four to 10 oxycodone 5 mg tablets, depending on the procedure. The comparison group received standard of care at the discretion of the prescribing surgeon and was sampled from the Michigan Surgical Quality Collaborative, a statewide registry that routinely collects clinical outcomes and patient-reported outcomes at 70 hospitals.

Both groups of patients were contacted between 30 and 90 days after surgery to complete their outcomes surveys. Primary outcomes were the number of opioid pills prescribed, the number of pills taken, the pain score in the seven days after surgery (ranging from 0 for no pain; 1 for minimal pain; 2 for moderate pain; and 3 for severe pain), satisfaction scale (scores ranged from 0 for extremely dissatisfied to 10 for extremely satisfied), regret scales (scores ranged from 1, signifying absolutely regret the surgery, to 5, denoting absolutely no regret), and quality of life (scores ranged from 1 to 5).

Patients in the opioid-sparing pathway received smaller prescriptions, used fewer pills, and reported less pain following surgery compared with those who received standard of care. In the opioid-sparing pathway 36.8% of patients did not receive an opioid prescription as compared to 0% of those who got standard of care.

When it came to patient satisfaction, regret, and quality of life, there was no difference between the two groups.

"This is a really good study," said Dr. Ismail El-Hamamsy, a professor of cardiovascular surgery at the Icahn School of Medicine at Mount Sinai and director of aortic surgery for the Mount Sinai Health System in New York City.

"The reality is that in our fields of surgery and pain management after surgery there has been a lot of focus over the last couple of decades to try to reduce pain sensation after surgery in all patients," said Dr. El-Hamamsy, who wasn't involved in the study. "There was a consensus that if we could eliminate the early experience of pain after surgery, we could significantly reduce the incidence of chronic pain in patients."

"For many years there was this notion that if you were taking opioids for pain there is no way you will have an addiction," Dr. El-Hamamsy said. "So, all these pain scales were developed. The goal for pain management teams was to get a number on the scale that was as low as possible."

But then a new problem developed, Dr. El-Hamamsy said. "And now the pendulum is swinging back. We realize now that we had been a little too liberal with the use of opioids. Pain management intensions were good. But there were unintended consequences, and unfortunately a lot of addictions."

The new study "is very timely," but it does have limitations, Dr. El-Hamamsy said. "It's small and not randomized," he added. "The procedures are not necessarily super painful. But it has an important message and it should serve as a basis to encourage all teams to think differently about how to manage pain."

SOURCE: JAMA Surgery, online January 27, 2021.