Patient Education

Opioid Crisis

Harms of Use

Opioids are powerful pain relievers that surgeons may prescribe to manage acute or chronic pain. Opioids block pain signals in the brain. But if patients abuse opioids or do not take them correctly, opioids can cause overdose and even death.

More than 2 million Americans abuse opioids, which can create a feeling of euphoria, and make the body believe the drug is necessary for survival. Since 2000, deaths in the United States from opioid overdoses have increased 200 percent.

Anyone who takes prescription opioids can become addicted; however, addiction is rare when opioids are used for five days or less.

Risk assessment – Who is at Risk?

Opioids are needed for pain control after surgery because of the drug’s powerful effect. The use of opioids after surgery is planned as a short-term strategy to relieve pain while the body heals, but the risk of abuse is still a concern. Opioids can cause side effects including: nausea, vomiting, constipation, urinary retention, drowsiness, impaired thinking skills and poor respiratory function.

The U.S. surgeon general launched an initiative in 2016 to address the growing problem of opioid overdose and misuse. The program has initiatives for doctors to educate their patients, screen and regularly reassess for misuse of opioids, assess pain management regularly, use nonopioid drugs when possible, and treat addiction. The program also provides strategies to help patients lessen risks for themselves, as well as others:

• Take medication only as directed, minimize dosage and duration of opioid use
• Talk to your doctor if your pain is not under control
• Do not use alcohol while taking opioids
• Use your opioids for your surgical pain only; do not use your pills for other reasons
• As your pain gets better, wait longer between taking opioids
• Follow your doctor’s instructions about other drugs not to take while using opioids
• Safely store drugs
• Dispose of unused drugs, ideally through a pharmacy take-back program
• Don’t share your medication with other people
• Diversion (sharing or selling) of opioids is considered a felony

Opioid Use in Surgical Patients

Expectations for postoperative pain

Surgery is painful and may leave patients sore and uncomfortable for a few days after, whether recovering at home or in the hospital. Pain is different for everyone; pain may be dull, stabbing, cramping, throbbing, constant, on and off. Treating pain early usually brings quicker and better control. Modern pain medications can control pain and help the body heal. Controlling pain and minimizing side effects are important in terms of patient comfort, recovery, and rehabilitation. Pain affects blood pressure, heart rate, appetite, and general mood.

For patients undergoing surgery, it’s natural to have concerns about pain after the procedure, as well as the risks associated with powerful pain medications; however, the time to talk about post-surgical pain relief and pain medications is before the surgery: preparation can lead to more effective pain management.

Pain control after surgery enhances patient comfort but it also speeds recovery and may reduce the risk of developing certain complications after surgery, such as pneumonia and blood clots. If pain is well controlled, patients will be better able to perform important tasks, such as walking and deep breathing exercises.

Patients will feel different kinds of pain after surgery, and the site of surgery is often not the only area of discomfort. Three common sites of pain after surgery include: 1) muscle pain, 2) throat pain, and 3) movement pain. Muscle pain may include pain in the neck, shoulders, back, or chest from lying on the operating room table. Throat pain may consist of a sore or scratchy feeling from the tube placed during anesthesia. Patients can use throat lozenges to ease throat discomfort. Movement pain, such as sitting, walking, and coughing, may cause increased pain at or around the incision pain.

How to have less pain after surgery

Stay ahead of the pain

Take (or ask for) pain relief medicine when pain first begins. Getting ahead of the pain means not waiting until pain is severe before taking your medication. If you wait until your pain is severe or increasing, it will become more difficult to control your pain, especially because you have to wait for the medication to be absorbed by the body to take effect.

In the days following your surgery, try taking the pain medication as prescribed by your surgeon. As your pain improves, try to extend the time between doses until you are able to quit altogether. Pain can be a normal part of the healing process, but pain that is unmanaged, impossible to control, or getting worse instead of better, may be a sign of a serious problem.

Consider non-prescription pain medication

Patients don’t necessarily need to choose between taking prescription pain medication or no pain medication. If your surgeon approves, over-the-counter pain medication may be used to take care of pain that is not severe enough to require prescription drugs, but not improved enough for no pain medication. Acetaminophen (such as, Tylenol), aspirin, ibuprofen (such as, Motrin), and other non-steroidal anti-inflammatory drugs (NSAIDs) reduce swelling and soreness and relieve mild to moderate pain.

There is no risk of addiction to non-prescription pain medicines. Depending on how much pain you have, these medicines can lessen or eliminate the need for stronger medicines (such as, morphine or another opioid). Most NSAIDs interfere with blood clotting, and may cause nausea, stomach bleeding, or kidney problems. For severe pain, an opioid usually needs to be added.

Get enough sleep

Sleep is one of the most important things patients can do to control pain. Adequate sleep improves their ability to cope with pain, speeds healing, and can actually reduce pain. The trick is to reduce pain enough to sleep well, which may require medication along with proper positioning. More tips on how to improve sleep after surgery:

https://www.verywellhealth.com/insomnia-and-poor-sleep-quality-after-surgery-3156873

Increase physical activity slowly

What may feel good when you are doing it, may not feel so good a few hours later. When recovering from surgery, feeling better may seem like an invitation to return to your normal physical activities. But, it is very easy to do too much, which increases pain levels and makes it more difficult to move forward with your activity level.

Sitting for too long

Sitting or lying down in one place for too long can lead to more pain. Getting up and walking every hour or two helps keep you from getting stiff, and has the added benefit of decreasing the risk of developing blood clots after surgery.

Many people avoid walking because they experience pain when moving from a sitting to standing position. If pain is so severe that you are unable to complete simple tasks, such as standing and walking, you should consult your surgeon.

Brace your surgery site

A simple thing you can do to prevent surgery pain is to brace your incision site. Bracing just means holding your incision/surgery site when you do anything that can cause stress on the site, such as standing up, sneezing and coughing. Minimizing the stress on your incision will reduce the pain you feel at the site.

Reduce Stress

Stress is the enemy of good pain control. An increase in stress can and often does increase pain. Surgery is a type of physical stress, and while that cannot be avoided, emotional stress can be minimized. In the early days of your recovery, try to avoid situations—and even people—that tend to increase your stress level. Stress reduction techniques, such as deep breathing and relaxation exercises, can be very beneficial.

More tips for improving surgery pain can be found at:

https://www.verywellhealth.com/tips-for-improving-surgery-pain-3156819

Hernia Surgery

Patients who have hernia surgery often underestimate how long their recovery will take, and recovery varies from one patient to the next. One patient who undergoes open surgery may have little to no pain afterwards, whereas another patient who undergoes laparoscopic surgery may develop moderate to severe pain.

Most patients feel better by a few weeks after hernia surgery. Some patients have groin pain that may last for months—or even years—after surgery. Two main causes of pain following hernia repair surgery are: 1) reaction to the mesh itself as the mesh used in hernia repair sometimes causes inflammation or irritation leading to pain; 2) nerve disturbance from the any of three major nerves that run through the abdominal area, which may get caught in a suture or the mesh resulting in chronic pain.

Patients are encouraged to keep a pillow handy to put over their abdomen for support in case they cough, sneeze, or vomit (which can be a side effect of anesthesia). Incision(s) may be sore for two or three days and may be swollen, bruised, tender, or numb, but this is normal and should go away within a few weeks.

Over-the-counter pain medicines such as Tylenol can sometimes control pain after hernia surgery. Some patients may need stronger pain medicines to control their discomfort. Opioids or narcotics may be needed for the first two days after surgery. Pain medicines have several side effects including nausea, constipation and sleepiness.

Colorectal Surgery

The amount of pain after colorectal surgery varies for each patient. Pain after surgery depends on patient-related health factors and how much of the colon was removed. Following a laparoscopic procedure, pain is sometimes felt in the shoulder, which is due to the gas inserted in the abdomen during the procedure. Moving and walking help to decrease the gas and the shoulder pain.

Most patients need intravenous pain relief for a couple of days after major bowel surgery. The most commonly used device is called a “patient controlled analgesia” device or PCA, which consists of a syringe filled with pain relief (usually morphine or fentanyl) attach to a pump. The patient presses a button on a hand held device and a measured dose of the drug is pumped into the vein. An epidural (pain relief through a tube into the spine) is occasionally used for pain relief in the first few days after surgery. Epidural pain control is mainly used for patients who have pre-existing lung disease or those who require a long midline incision.

Once the gut begins to work, patients will be switched over to oral medications for pain relief. Oral medications may include regular paracetamol and other drugs, such as oxycodone (Endone) on an as required basis.

After hospital discharge, it is normal for patients to experience some abdominal discomfort, from either the wound or windy pain from the bowel itself. This discomfort should gradually improve over several weeks. Patients should continue taking their pain control medications until they feel comfortable. Good pain control helps patients mobilize and sleep, which are two important components of getting back to normal.

Simple measures such as supporting the abdomen with a cushion when coughing (or when wearing a seat belt) will help avoid putting strain on the wound and make patients more comfortable.

Upper Gastrointestinal (GI) Surgery

As with any type of surgery, it is reasonable to expect some amount of pain after upper GI surgery. Pain after surgery varies for individual patients and depends on the body’s response to pain medication.

A combination of pain relief may be used to keep patients as comfortable as possible after surgery. If needed in the recovery room, pain medicines may be given through the intravenous catheter or patient-controlled analgesia.

When patients are able to drink, they may be given pain relief by mouth. After hospital discharge, some patients may need prescription pain medication as well as medication for nausea. Tylenol is frequently used to decrease the amount of narcotic needed.

Hepatopancreatobiliary (HPB) Surgery

It is normal for patients to have some pain after HPB surgery. The amount of pain experienced after surgery differs between patients. Immediately after surgery, intravenous (IV) pain medications will be used to treat pain. Two common IV pain medications are morphine or Dilaudid. Pain control after surgery is important so patients can cough, breathe deeply, get out of bed, and walk.

Once patients are able to eat a solid diet, oral pain medications will be used to treat pain. Common oral medications are hydrocodone (Norco) and tramadol (Ultram). Prescription pain medications help patients to recover comfortably, but patients should stop them as soon as possible. Side effects of nausea, vomiting, dizziness, fatigue, poor appetite, and constipation, are common with prescription pain medications. If patients have these issues, try to use Ibuprofen and Tylenol instead. Sleep aids should not be used while patients are on narcotic pain medications.

Appropriate use / Normal number of pills

Most patients report using less than half of their opioid pills; many patients do not use any of their pills. The best predictor of home opioid use is opioid use the day before discharge. For patients who are discharged from the hospital after surgery, we lack data to inform appropriate opioid prescribing. The following prescribing guidelines may be appropriate for patients without complications who are not chronic opioid users and discharged to home after inpatient general surgery (e.g., bariatric, benign foregut, liver, pancreas, ventral hernia, and colon surgery):

• For patients discharged on POD 1, 15 pills.
• For patients discharged on POD 2 or later, the discharge prescription is based on the number of pills taken the day before discharge.
• For patients who took no pills the day before discharge, no opioids should be prescribed.
• For patients who took 1 to 3 pills the day before discharge, 15 pills should be prescribed.
• For patients who took 4 or more pills the day before discharge, 30 pills should be prescribed.

https://www.journalacs.org/article/S1072-7515(17)32055-0/pdf

A summary of best practices for opioid prescribing for patients discharged after surgery from Michigan may be considered also:

• Non-opioid therapies should be encouraged as a primary treatment for pain management (e.g., acetaminophen, ibuprofen).
• Non-pharmacologic therapies should be encouraged (e.g., ice, elevation, physical therapy).
• Do not prescribe opioids with other sedative medications (e.g., benzodiazepines).
• Short-acting opioids should be prescribed for no more than 3 to 5 day courses (e.g., hydrocodone, oxycodone).
• Fentanyl or Long-acting opioids such as methadone, OxyContin and should not be prescribed to opioid naïve patients.
• Consider offering a naloxone co-prescription to patients who may be at increased risk for overdose, including those with a history of overdose, a substance use disorder, those already prescribed benzodiazepines, and patients who are receiving higher doses of opioids (e.g., >50 MME/Day).

https://www.michigan.gov/documents/lara/Acute_Care_Opioid_Treatment_and_Prescibing_Recommendations_Surgical_-_FINAL_620739_7.PDF

Safe Storage and Safe Disposal of Opioids

How to safely store opioids

The abuse of opioids is a public health problem. Teenagers and young adults commonly get opioids from medicine cabinets in their home, where another family member has stored them. All opioids should be stored in their original packaging inside a locked cabinet, lockbox, or a location where others cannot easily access them. Patients should carefully note when and how much medication they take, in order to keep track of how much remains. If you think someone has taken your opioids, contact the police immediately to file a report.

How to safely dispose of opioids

After the patients’ acute pain phase has ended and the medication is no longer needed, it is critical to dispose of the leftovers promptly. In an exception to the general rule, the FDA allows opioids to be flushed down the toilet; however, more environmentally friendly disposal methods are encouraged.

Medication take-back programs

Many communities have medication take-back programs. Ask your family doctor for more information or visit the U.S. Drug Enforcement Administration’s Office of Diversion Control to learn more. Patients can also call their local waste management company to ask if there is a take-back program in their community.

Opioids—both pill and patch forms—often come with instructions for flushing unused medicine to prevent unintentional use or illegal abuse.

The FDA recommends always flushing used and leftover pain patches down the toilet. Even used patches still have enough medicine in them to be dangerous or deadly to pets, children, and others with a low tolerance for opioids. To dispose of a pain patch, fold it in half so the sticky sides stick together, then flush it immediately.

What if my community doesn’t allow flushing unused pills?

If your community warns against flushing unused medicines down the toilet, take the following steps instead:

1. Remove the medication from its original container, and remove any labels or cross out identifying information.
2. Mix the pills with something that can’t be eaten (e.g., kitty litter, coffee grounds, sawdust, home cleanser).

3. Place the mixture in a sealable bag, empty can, or other durable container that prevents leakage.
4. Wrap the container in newspaper or a plain brown bag to conceal its contents. Place it in your trash the day regular trash is collected.

Additional Resources

http://www.corxconsortium.org/wp-content/uploads/Safe-Disposal-Brochure.pdf

http://www.deadiversion.usdoj.gov/drug_disposal/takeback/index.html

https://apps.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e1s1

Alternatives to Opioids for the Treatment of Pain

Alternative Medications

Ketamine

Ketamine has been used extensively in the emergency department for procedural sedation and rapid-sequence intubation. Recent research shows that a low (subdissociative) dose (0.1-0.3 mg/kg IV) is safe and effective for pain management. Due to the relatively short-lived analgesic effects of the drug, the initial bolus can be followed by an infusion (9-30 mg/hour) for sustained effect. Caution should be used in any patient with a significant psychiatric

history, and use should be avoided in patients with a history of post-traumatic stress disorder.

Lidocaine

Lidocaine is an ideal agent for treating visceral and central pain, and also may be useful when narcotics are inefficient or lead to undesirable side effects. Intravenous or topical (4% or 5% transdermal patch) doses are effective for controlling renal colic and neuropathic pain associated with conditions such as diabetic neuropathy, postoperative or post-herpetic pain, headaches, and neurological malignancies. Intravenous lidocaine should be used with caution in any patient with a significant cardiac history. Side effects of the drug are minimal when used sparingly.

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to manage most painful conditions, particularly musculoskeletal pain, migraine, and renal colic. These agents can be administered intravenously, intramuscularly, orally, and topically. For ketorolac, literature supports using a maximum intravenous dose of 15 mg, as higher doses do not increase efficacy and may introduce unnecessary harm. Caution should be used in patients with renal dysfunction or heart failure, or when there is a concern for bleeding. For these subpopulations, consider topical choices such as diclofenac gel or a patch. Topical agents have significantly lower systemic absorption and lower rates of adverse drug events.

Haloperidol

Haloperidol is a “typical” or first-generation antipsychotic agent. It can be administered intravenously, intramuscularly, and orally and often is used for the treatment of psychiatric emergencies. The drug also can be used in low doses as an adjunct treatment for pain and nausea. At doses of 2.5 to 5 mg, haloperidol is effective for the management of abdominal pain and migraine-associated headaches. Anecdotally there has been a rise in the number of haldol “allergies.” If a patient’s reaction is suspected to stem from a true allergy rather than an extrapyramidal side effect of the drug, olanzepine is a reasonable alternative.

Dicyclomine

Dicyclomine is an antispasmodic and anticholinergic agent that acts to alleviate smooth muscle spasms in the gastrointestinal tract. It is effective for treating abdominal pain, particularly caused by cramping. The drug can be administered either orally or intramuscularly, but should not be administered intravenously. Due to its anticholinergic action, dicyclomine should be avoided in the geriatric population.

Psychoactive drugs

Some psychoactive drugs that may be used for treating pain after surgery include the anti-anxiety medication midazolam or the anticonvulsants gabapentin (Gralise, Horizant, Neurontin) and pregabalin (Lyrica).

Non-pharmacologic alternatives

Pain control after surgery is a priority for patients and surgeons. Although patients should expect to have some pain after surgery, coping with pain after surgery doesn’t have to mean just taking more prescription pain medication. Patients need to understand options for pain control that empower them to take an active role in making choices about pain management.

Pain medication has its place in pain management, but additional strategies can be used to help patients deal with pain after surgery. Non-drug pain relief methods have no side effects and can be effective for mild to moderate pain. They boost the effects of drugs and are best learned before surgery.

Patient teaching

Learning about the operation and the pain expected afterwards (for example, when coughing or getting out of bed or a chair). Patient teaching techniques can reduce anxiety; they are simple to learn, and no equipment is needed.

Activity

Patients are advised to start moving as soon as possible after surgery. Moving helps with breathing and digestion, which helps the body heal faster. It may hurt to move even though moving and gradually being more active lessen pain over time. Patients may initially need to rest in bed with their upper body raised on pillows.

Relaxation

Simple techniques, such as abdominal breathing and jaw relaxation can help increase comfort after surgery. Relaxation techniques are easy to learn and help reduce anxiety. Relaxation media can be purchased at local bookstores, online stores, or borrowed from local libraries. Patients can bring their relaxation media and listening device to the hospital to play prior to surgery and during their hospital stay.

Guided imagery

Guided imagery is a proven form of focused relaxation that helps create calm, peaceful images in your mind—a form of mental escape.

Music

Whether patients prefer to listen to music, sing, hum, or play an instrument, music increases blood flow to the brain and helps patients breathe in more air. Music has a positive effect on mood and increases energy levels.

Distraction

Distraction brings the mind’s focus on something other than pain. Playing cards or games, talking with family, and reading may help patients feel relaxed while thinking about something other than pain.

Comfort measures

Holding a pillow firmly against the incision site may help lessen the pain. If you need to get more comfortable, ask someone for more pillows and blankets.

Cold and heat

Both cold and heat can help lessen some types of pain. Some types of pain improve most by using cold and some types improve most by using heat.

Integrative therapies

Integrative therapies use a patient-centered approach and begin preoperatively with proper nutrition using an anti-inflammatory diet with plant-based foods. Tumeric has been used in addition to and as an alternative to NSAIDs because of its anti-inflammatory properties. Some integrative therapies, such as acupuncture, acupressure, yoga, and massage, are centuries old. Their broad safety margin and patient acceptance offer a non-pharmacologic approach to pain after surgery.