For one in 10 surgical patients, surgery is the gateway to long-term opioid abuse. Oregon has one of the highest rates of prescription opioid misuse in the nation. As doctors who care for you in the operating room as well as in the pain management clinic, physician anesthesiologists are uniquely poised to help combat Oregon’s opioid crisis.
Before Surgery
We can predict which patients have a higher likelihood of post-operative opioid dependence. Some are more intuitive, such as a history of depression or anxiety, history of substance abuse and pre-existing chronic pain. Others may be more surprising, such as male sex, tobacco use and age >50 years.
Expectations play a pivotal role in managing postoperative pain. Patients who expect to feel no pain are gravely disappointed after waking up from their lumbar spine fusion. Conversely, the new mother who is pleased with a 5 on the 1-10 pain scale after her C section is less likely to take as many pain pills in search of the elusive “zero”.
Of course, patients who are taking pain medicine regularly prior to surgery are encouraged to continue their regimen through the perioperative period. Weaning oneself off one’s oxycodone in the week prior to surgery only causes increased preoperative, and thus postoperative, pain.
During Surgery
We won’t pretend that opioids are not necessary. In fact, there are many surgeries in which withholding opioids would be cruel. Physician anesthesiologists are experts in pharmaceutical cocktails, utilizing a bit of this and a touch of that to maximize pain relief while minimizing adverse effects.
Non-opioid pain medicines are part of our daily armamentarium. Acetaminophen and anti-inflammatories are routinely administered, and adjuncts such as gabapentin and ketamine are often employed to mitigate the doses of opioids required for acceptable analgesia. In certain surgeries, intravenous infusions of local anesthetics have been proven to be beneficial.
Rendering the body insensate to pain is the greatest tool we have in decreasing surgical pain. Epidurals, caudals and spinals involve injection of numbing medicine around the spine, which works well for chest, abdominal and leg surgeries. One of my greatest joys is watching the relief wash over a patient’s face after placing a lumbar epidural for their complicated pelvis fractures.
There are dozens of nerve blocks described, in which a local anesthetic is injected in the arms, legs or torso to target pain relief at the site of surgery. With the use of super long-acting medications or continuous infusions, a patient may experience 3 blissful days of numbness after a total shoulder revision.
Some surgical scenarios are ideally suited to a trend called “Opioid Free Surgery.” Of course it requires motivated patients, appropriate surgeries and agreeable surgeons, but patients should feel free to talk to their physicians about this if they’re interested. A nice summary of this concept from the Mayo Clinic can be found here.
After Surgery
The mere act of prescribing opioids upon hospital discharge to an opioid naïve person can lead to long-term opioid abuse. Being able to taper a patient off opioids prior to discharge may decrease that risk. Physician anesthesiologists often manage the Acute Pain Service in hospitals. During our four-year residency, we spend months learning about both acute and chronic pain management. For that reason, we are expert consultants at managing all sorts of pain scenarios, from simple epidural infusions after lung surgery to creating an effective regimen for a patient on Suboxone (a medication that blocks the effects of opioids.)
If a patient requires more long-term help with their pain, physician anesthesiologists are located in Pain Management clinics throughout the state. These physicians completed an additional fellowship in pain medicine after their residency, and they are uniquely positioned to perform medication management as well as interventional procedures with the goal of decreasing opioid use over time.
Thank you for helping us celebrate Physician Anesthesiologists Week. We jokingly mutter that our motto is “Blame Anesthesia,” and a job well done in the Operating Room or Pain Clinic often means that no one remembers us. But when you ponder our ability to render you unconscious for surgery (then carrying on a conversation by lunch), or our prowess at numbing all parts of the body with an ultrasound probe and needle, you might start to refer to us as “Wizards.”
Dr. Kate Ropp is president of the Oregon Society of Anesthesiologists. You can reach her at [email protected].
