In retrospect, we were an addicted nation waiting to happen. Not from a self-indulgent culture, not from an unwillingness to suffer hardship, nor any of the generational criticisms of lack of grit. Our opioid crisis derives from an impatient culture that fears loss of health more than health care profit. With pain as most people’s proxy for health, we were primed for a quick fix when Oxycontin arrived. While Enhanced Recovery After Surgery (ERAS) isn’t quick, understanding and addressing post-op pain with ERAS will slow or stop the flow of new opioid use disorder (OUD).
To set the stage, think about most post-operative scenarios. In a culture where age is suspect and dementia a growing specter, pain presages irrelevance. At home alone after surgery, ongoing or increased pain causes fear, foreshadowing, or medical bankruptcy? Ongoing infirmity? Medical mistakes? Accepting that your elbow may never be pain-free means accepting that you’re on the back nine of life, not just your golf game: a quick opioid dopamine rush is easier to accept than decrepitude.
As I’ve discussed in a previous essay, deceptive marketing changed our tolerance for post-operative pain in the 1990s. Similar profit-driven HMO establishments encouraged giving the “customers” whatever they demanded. Opioid reimbursement was given: Medicare and Medicaid’s 1882 directive to cover “illness, injury, and bodily malformation” means pills are almost always paid for. By CMS’ interpretation of this archaic health directive, immobilization is covered, and chronic pain is irrelevant. Despite the success of the nascent biopsychosocial approach to chronic pain, profit-motivated payors quickly shifted to covering opioids rather than a multimodal approach for chronic pain as well as post-op.
What we didn’t understand about opioids is that approximately 15% of people are genetically susceptible to lifelong cravings. With IV hospital opioids or fewer than three days of exposure, the risk is minimal. However, an average of 6% of those having surgery – any surgery, from wisdom tooth removal to a total knee replacement – prescribed outpatient opioids develop opioid use disorder. With 64 million surgeries, this is 3.8M new family tragedies every year.
Since 60% of post-op pills go unused, our prescribing practices contribute to around 500 million available pills a year, brown-orange bottles seductively waiting in drawers and cabinets for experimentation. Surveys show that 60% of opioid misuse starts with free pills taken from friends and family. Leftovers lead to 1 million new young opioid users and party overdoses from fentanyl that look so benignly like what lies unmonitored at home.
So here’s the good news: if the estimates of OUD after surgery and new misused OUD from leftover pills are correct, by providing alternative pain control at home after surgery, physicians can prevent almost ALL new OUD. Enhanced Recovery After Surgery (ERAS) was initially coined in 2001 to refer to the biopsychosocial multimodal approach to pain. In practice, it includes preoperative coaching, pain teaching, and expectation management, then intraoperative long-acting nerve blocks, over-the-counter medications, and early movement at home. (In contrast to the immobilization we pay for, increasingly, we’re learning that movement is medicine.)
ERAS has lowered home opioids from 30 pills to single digits in study after study. With recent advances in understanding how to hack your brain when you’re in pain, ERAS options are so much more robust. These six additional evidence-based opportunities cost less than $100 a person; even if all 64 million post-op opioid avoiders got a stipend, that’s $6.4 billion compared to the $2.5 trillion in OUD costs.
Consider:
Magnesium. This potent anti-inflammatory reduces intraoperative opioid needs by 1/3, is necessary to couple with pain and inflammation-relieving oxytocin, and reduces the irritability and constipation that increase pain. Since only 1% of magnesium stores are in the blood, levels that may be low normal are actually deficient. An estimated 66% of those going into surgery are magnesium deficient. Start 400 mg of whatever formulation is cheapest three days before surgery: $12.
Meditation. Reducing the autonomic responses to pain may be associated with cortical alpha rhythms that can decrease the anxiety and focus that intensify pain. Start one month before surgery: free.
Tactile and autonomic hack. Physical touch takes the attention away from the area of fear, and breathing and touch combined enhance the association of calmness with lack of pain. This is a great video with techniques and a wonderful explanation by Judith Scheman, PhD, for before and after surgery.
Vibration and cold. A vibratory frequency of 200 Hz stimulates the proprioception nerves and stops the nociceptor pain nerves from transmitting pain in the dorsal horn of the spinal cord. Cold decreases nerve transmission locally and reduces inflammation and central pain. The two together reduced opioid use by 35% in a pilot ACL reconstruction study compared to a coaching regimen. Cost: $65.
Hydration. Even mild hypohydration (yellow pee) increases pain. Getting up after surgery is movement (the aforementioned medicine). Combining hydration and more post-op pee: free.
Other neurotransmitter options. Opioids stimulate dopamine, so you don’t mind or notice pain. Other neurotransmitters do, too. Planning serotonin-releasing friend visits, oxytocin-elevating massages, or dopamine-releasing movie watching or game playing reduces pain. This free workbook can take the FTEs out of pre-op coaching.
Our opioid crisis stems from too many opioids after surgery and in circulation and too little use of non-drug options. The barriers to opioid-sparing pain management are legion: physician’s lack of options, knowledge, lack of time, expectations of patients, and lack of reimbursement, both for pain relief and pain management education. While copious literature on chronic pain opioid reduction barriers exists, the few in the surgical realm still focus on drug alternatives. Pain is pain. Chronic pain patients don’t overdose as often and certainly don’t have leftovers that lie around. To solve the problem of new OUD and opioid-naive overdoses, let’s move the focus from chronic pain. The numbers support that if we eradicated unnecessary post-op opioid prescribing, that would be the solution.
Amy Baxter is a clinical associate professor of emergency medicine at Augusta University, federally funded for neuromodulation research to reduce needle pain, multimodal low back pain, and opioid reduction. After attending Yale University and Emory Medical School, she completed her residency and a child maltreatment fellowship at Cincinnati Children’s Hospital Medical Center, an emergency pediatrics fellowship in Norfolk, Virginia, and a K30-NIH Clinical Research Certificate at UT Southwestern Medical Center. She is also CEO, Pain Care Labs, and can be reached on Twitter @AmyBaxterMD.
