As we follow the national opioid epidemic, with its greater than five deaths per hour from opioid overdoses, the focus is shifting to methods for limiting an individual’s exposure to these drugs. For most of us, our first contact with these highly addictive medications is after surgery.
Studies now reveal that 60 percent of pills prescribed for pain after surgery go unused. These opioids often make their way to other family members, are kept for continued use by the surgical patient to maintain a feeling of euphoria, or even find their way out into the community. Limiting the number of pills and refills prescribed is a good start, but should we consider not using opioids, or discharging surgical patients on them, at all? With the advent of new anesthetic techniques and a long-acting nerve-blocking medication, this option is now a reality. We shall look at two commonly performed surgeries where we are seeing a spike in opioid dependence in relatively young, healthy patients.
Shoulder surgeries and cesarean sections occur on a daily basis across the country. With over 700,000 shoulder procedures and over one million cesarean sections performed each year, thousands of these young-adult patients will go on to be persistent opioid users. There are several pre-existing conditions that can contribute to continued use, such as whether a patient is a smoker or has been diagnosed with alcohol- or drug-based issues or depression, anxiety or chronic pain conditions before surgery, but that is beside the point. It goes without saying that individuals with a genetic or behavioral predisposition to abuse opioids should be forewarned and treated accordingly, but why not avoid the opioid exposure issue with these patients altogether?
Until recently our post-operative pain management for shoulder surgery has been limited to either a single injection of local anesthetic to numb the nerves sensing the pain or placing a small tube under the skin that provides a continuous supply of anesthetic. Both of these techniques have their limitations and drawbacks. However, the FDA has recently approved the use of a long-acting local anesthetic for shoulder surgery patients. We are now utilizing this medication by providing a single injection, guided by ultrasound. Our results have been excellent. Most patients have high levels of pain relief lasting between 48 and 72 hours. Individuals can then transition to acetaminophen and ibuprofen without the need of an opioid.
As with shoulder surgery patients, we can now also apply this long-acting local anesthetic under ultrasound guidance after a Cesarean delivery. Obtaining 48 to 72 hours of pain relief again avoids the need, in most cases, for opioid use at home. New mothers have enough on their plate and our ability to provide long-lasting pain relief without opioids is essential.
These are just two surgical examples of how newer anesthetic techniques and medications can play a role in providing individuals with extended pain relief after surgery. We are applying this knowable to every surgical procedure and observing dramatic decreases in opioid utilization.
Yes, the era of opioid-free surgery has arrived.
Myles Gart is an anesthesiologist.
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