June 27, 2019
By Saumya Joseph
(Reuters Health) - Surgery patients who were taught to manage their pain with acetaminophen and ibuprofen ended up using few or no opioid pills, a recent study found.
Volunteers in the study underwent one of six minor surgeries: laparoscopic gallbladder removal, laparoscopic repair of a groin hernia, removal of the thyroid or parathyroid gland, robot-assisted removal of the prostate, endoscopic sinus surgery, and laparoscopic sleeve gastrectomy.
Before the surgery, the 190 volunteers received counseling on pain management and were advised to take a non-opioid pain reliever every three hours, alternating between 600 milligrams of ibuprofen and 650 mg of acetaminophen.
Researchers also gave patients a small prescription of 5-mg pills containing the opioid oxycodone, counseling them to take the narcotic only if their pain was unmanageable.
When researchers contacted the patients one to three months after the surgeries, they learned that 52% hadn't used any opioids at all.
Among those who did use opioids, 98% used no more than 10 pills and almost all agreed that their pain was manageable under this regimen, the researchers report in Journal of the American College of Surgeons, online May 31.
"Over the years, surgeons often prescribed 20 to 40 oxycodone tablets after many procedures. This study and others like it suggest that those quantities were not necessary in many cases," said Dr. Kevin Hill of the Harvard Medical School in Boston, who was not involved in the study.
"The efficacy of this protocol is more about expectation setting, education and using non-opioid pain medications which are very powerful," coauthor Dr. Chad Brummett of the University of Michigan Medical School in Ann Arbor told Reuters Health by phone.
"The fundamental concept is that we as surgeons and dentists are gatekeepers to opioid exposure," said coauthor Dr. Michael Englesbe, also of the University of Michigan. He noted that most heroin users and people at risk of overdose got their first exposure to opioids from a medical care provider.
Up to 10% of patients who take opioids for the first time after an operation develop long-term dependence, and this risk of dependence has been found to be associated with the size of the initial prescription, the researchers note.
Prior studies have also found that patients tend to have about 19 leftover pills after their recovery. In the current study, half the patients had no more than two pills left over from the small supply they had been given.
Excessive prescribing of opioids increases the risk of prolonged use and results in leftover pills getting diverted and being abused by others, especially adolescents.
In 2017 in the U.S., an estimated 11.4 million people aged 12 or older had misused opioids in the past year, according to data from the National Survey on Drug Use and Health.
The study results prove that many surgery patients don't need opioids to manage pain and that use of these painkillers needs to be de-emphasized where possible, said Beth Darnall, a pain researcher at the Stanford University School of Medicine in California, who also was not involved in the study.
"That said, some patients absolutely need opioids, and we need to be mindful of this variability," she added.
Brummett and Englesbe and their colleagues acknowledge in their report that this approach "might not be appropriate for more complex procedures." Going forward, they hope to learn more about its feasibility across multiple surgical procedures and across a diverse patient population.
"It will be important to understand the patient characteristics that favor the use of this pathway," they conclude.
J Am Coll Surg 2019.
(c) Copyright Thomson Reuters 2019. Click For Restrictions - https://agency.reuters.com/en/copyright.html