Opioid Dependence After Surgery Is Even Worse Than Physicians Thought

Editor’s Note: Scott Sigman, MD, is a team physician for the University of Massachusetts Lowell. He is also an appointee on the Governor Charlie Backer’s special commission to establish a pain management program for the Commonwealth of Massachusetts. Although he was not an author on the study discussed below, he is a spokesperson for the Choices Matter campaign and frequently offers his patients non-opioid alternatives to combat the epidemic — which led to his interest in this research. The study included 500 adult patients who had either soft tissue or orthopedic surgery within the previous year and were given short-term postsurgical prescriptions, defined as up to 10 days, and the 200 surgeons who performed the procedures in the United States.

MD Magazine: Before this new research was conducted, what did doctors think the rate of opioid addiction and dependence was after surgery?

SS: The number I’ve been quoting, and I’ve been doing this for quite some time, was always one out of 15. That’s where most of the studies have sort of landed. I was very surprised in this survey to see that it was really closer to one out of 10 that patients were describing dependency on narcotics, which it sort of helps to explain a little bit as to why this opioid crisis was really blown out of control at this point.

MD Magazine: What are some of the populations that doctors are most concerned about for opioid addiction and dependence?

SS: It’s interesting. Another very important point out of the survey which I saw which was really fascinating is that 90% of prescribing surgeons felt a pressure to prescribe more narcotic. That really jumped off the page for me. I’m sure you’re aware with the HCAHP scores that were put together with Obamacare and CMS in the attempts of trying to sort of manage patient care with surveys and patient reported outcomes. And two of the questions on that survey really dealt with pain. And the questions were, do you feel that you’re adequately, were you adequately covered with your pain management through your stay. So, in order to get a better HCAHP score, right, if you get a better HCAHP score, CMS will then actually pay you more money for the procedure because they feel that the patients are more satisfied, so therefore you earn more money for the actions you’ve taken. And so doctors felt compelled to write additional narcotic prescriptions because they wanted their patients to be able to report on the survey that their pain was managed appropriately which is obviously the exact opposite of what we’re trying to accomplish at this point.

MD Magazine: You said that the physicians in the study felt more compelled to prescribe more narcotics because they wanted their patients to be satisfied when they did fill out the survey. Do you think that this translates to everyday practice where doctors feel that pressure from their patients?

SS: Yeah, I do. So let me tell you what I’m doing in my clinical practice which has really changed for me. So I have a conversation with every single patient that walks through my door that winds up getting scheduled for elective surgery in advance of their surgery. And what I do is I specifically express to the patient about what my expectations are for what their pain will be. I tell every patient, it’s not possible for me to take away all of your pain. We’re going to make you comfortable. We’re going to get you through this. You will have some pain, it will be manageable, and here’s how we’re going to do it. And then I ask the patient, what are your expectations? Many times they’re saying, well, I have a niece, nephew, or a coworker who became addicted to medication, maybe even died in this crisis. I want to know, what options are there? And, for the most part, patients are really pleased, number one to know that I care and that we want to make sure that they get through the surgical experience in a safe fashion. They’re appreciative to know that there are options that are out there. And so the good news is for me is that I know this and I do this with every single patient. But there may be some doctors out there that aren’t completely familiar with all of the various alternatives that are out there.

MD Magazine: Do you think that it’s up to the physician or the patient to bring up the non-opioid possible approach or does the responsibility fall equally?

SS: Equally, 100%. I think we absolutely need to empower our patients to let them know that they have options, and we also equally need to make sure that our physicians are educated into the various alternatives. I saw a patient come down my hallway today. She’s 14 days after a total knee replacement. She is taking Tylenol, oral Tylenol right now. She’s walking without a cane or a knee mobilizer. At the time of her surgery, we injected a medication directly into the surgical site. We also gave her IV nonsteroidal medications. We gave her oral anti-inflammatories, and literally she walked home two days after surgery and is where she is at this point. And I firmly believe that these alternatives to opioids can be used quite successfully, even in the most major orthopedic surgeries.

Whenever I have this conversation about opioids, there are patients in chronic pain that are being successfully treated with opioids by pain management specialists for chronic pain scenarios — cancer, fibromyalgia, or other chronic pain syndromes. And those patients need to get continued care. I am not advocating that all opioids should be wiped out of the market. We want to care for those patients. We want to message that loud and clear.

MD Magazine: The survey results indicated that less than 25% of patients discussed non-opioid pain control options for surgery with their doctors. How can a physician better initiate that conversation with their patients?

SS: In my clinical experience, what I do, you literally have to talk about it with every single patient. And it is not done the day of surgery. It’s not done five minutes before the patient is rolling into the room. The conversation is had the minute that a doctor is consenting a patient for surgery in their preoperative operation in the clinic.

Now, some of these alternatives, to be perfectly honest, are not available in some hospitals across the country because of cost concerns. Because these medications that we’re using, which are opioid alternatives, are actually significantly more expensive than the opioids. Now, interesting, in the State of Massachusetts, I just recently had a conversation with the Health and Human Services Department, and over $300 million per year is now being spent on the Mass Health Medicaid population for patients that are in substance use disorder, $300 million a year. That’s a tremendous amount of money that’s being spent on the consequences of this epidemic. So I feel quite strongly that we need to be spending money on the front side of this epidemic to prevent the wave of patients that are coming into the system.

MD Magazine: How do you think that this new finding, that it’s not really one in 15 patients who become dependent but one in 10, will change the way that doctors treat their patients?

SS: I think it’s proving it’s even more urgent at this point now that we get this message across because we’ve all heard these stories. I mean, the 18-year-old kid that comes in. He’s a college athlete, he’s got a Division I scholarship, he has a torn ACL, he undergoes surgery, he’s prescribed narcotics by his doctor, and six months later he’s dead of IV heroin, or now Fentanyl which is the latest drug that we’re seeing used on the streets. And these kids are literally dead. It is urgent that we get this message across to all patients and doctors that these options are available. One out of 15 to one out of 10, I was really blown away by that number. It gives me a better sense of why this epidemic is really blooming as much as it is at this time.

SS: The Choices Matter program is specifically designed to empower patients to give them the options, to let them know that there are options to opioids during your surgical intervention. We get the fact that, again, going to a doctor can be a scary event. Most of the time you want to trust and just listen to the doctor, but what we want to do is let the patients know that you can help direct your care. Express to the doctor that you have questions and concerns. And, for example, you might not know what questions to ask, so there’s a website that’s been developed through the Choices Matter campaign that’s called planagainstpain.com. And you go on that website, click, fill out a couple of questions. There’s about 11 questions. It’s a survey and it will then allow you to print out a sheet of paper with a few questions that you can bring to the doctor, specifically to say, hey, doc, what alternatives are there?

I talk about pain as sort of the storm of pain. The worst of the pain in any surgical intervention is within the first 72 hours. So, if you can reduce that pain syndrome in that 72 hours, it’s not like at the end of 72 hours it’s just as bad as it was at the surgery, all of those pain generators have been flushed out of the system and patients get a much softer landing. They have much less need for postoperative narcotics and medication, and they can really navigate through the surgery quite well.

MD Magazine: Can you tell me about Gabrielle Reece’s (pictured above) role in the program?

SS: Gabby Reece is this amazing professional athlete. She’s the healthiest person I’ve ever met in my life. She really wanted to try and minimize her experience and exposure to medications. And basically she blew out her knee over multiple years as a professional volleyball player, and it got to the point where she just really no longer handled it anymore and she required a knee replacement. And about two months ago or so, she underwent a knee replacement and she basically said to the doc, look, I want to minimize narcotics. She took a couple of pain pills on the first day or so, but she basically left the hospital not taking any postoperative narcotics or prescriptive medications. And, look, she’s a professional athlete. She was able to tough through it through true grit, if you will, but she’ll be the first one to tell you that she struggled. And she’s struggling. She’s had a knee manipulation now to try to regain her motion.

She’s making slow and steady progress to recover, and if you ask her, she’s like, wow, had I know that these options were available, I really would have pushed my doctor to look for these other opioid alternatives to try and get me through this in an even better fashion. So she didn’t even know it was available. When she sort of got wind of this Choice Matters campaign, it fit perfectly into her and her being as a person, her lifestyle, the way she lives. And she wants the message to patients to say, look, you don’t have to do what I did. You don’t have to tough it out. If you don’t want to take narcotics, there’s great options that can help to get you through this. And she’s been a real leader and great spokeswoman in trying to message that for us.

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