Healthcare system launches new pain management option for surgical patients.
Intermountain Healthcare has launched a new opioid-free surgery option for those who struggle with addiction. Instead of fentanyl or hydromorphone, physicians would use a nerve blocker during an operation, and a few non-opioid painkillers in recovery. So far, 250 patients have opted into the new program, according to Intermountain surgeon Nathan Richards.
Richards explained, “Patients previously received about thirty opioid tablets following gall bladder removal. But patient surveys showed they only used, on average, five to seven of those pills.”
Will Shakespeare, Intermountain’s director of anesthesiology, recalled a teenager who, after an operation woke up and said, “Ouch” and was immediately met with painkillers.
“On further inquiry, the boy explained he said ‘ouch’ only because his arms were stiff from being stationary for so long,” Shakespeare said. “We don’t want to have that reflex to go to opioids for any discomfort…In some studies, opioid use during surgery has been shown to increase pain sensitivity after surgery.”
He added, “The most dangerous complication of surgery is persistent opioid use, as 6% to 7% of patients report they still use pain pills 90 days after surgery. Some, too, don’t like the nausea and constipation associated with pain pills. Intermountain has been pouring a lot infrastructure into the new protocols, especially in training surgical teams to administer the drugs.”
To date, 90 percent of those patients who underwent surgery using this new option reported adequate pain relief, according to Intermountain, which is focusing on those patients who know they have a substance use problem and are motivated to avoid opioid use.
Richards said everyone knows someone “who, through no fault of their own, has become dependent on opioids. A lot of the exposure to these potentially harmful medications comes from us physicians.”
“We thought that for all these years, we were putting water on the fire, when in fact, it was gasoline,” said Shakespeare. “There’s never a message saying, ‘Withhold opioids.’ If you need an opioid, it’ll be available.”
“I’m very happy to have an option for other people like me who want to do it without an addiction coming on,” Jason Zeeman, who has long struggled with opioid addiction, said. “I learned very quickly that addiction to opiates is very real.”
The new program abides by the following:
“Educate the patient and their families so they have a clear understanding of the risks of opioids and expectations about pain management post-surgery;
Have a patient start taking Tylenol the night before they come in for surgery;
When patients are in the preoperative area, give them a combination of non-narcotic medications, like another dose of Tylenol, an anti-inflammatory drug like Celebrex, and a nerve-modifying agent;
Use regional anesthesia such as nerve blocks and/or spinal-epidural anesthesia;
Use non-opioid pain medicines such as Dexmedetomidine, Ketamine, Dexamethasone, Esmolol, and other agents that have been shown to decrease postoperative pain;
Use long-acting anesthetics;
Use a pain pump. This is where a catheter is placed at the affected nerve site during surgery. Patients then take the device home and when needed can pump medication directly into the painful area;
Train patients in alternative pain management techniques, such as mindful breathing, focus management, and yoga exercises that can help them prepare for surgery and the recovery process.”
“In some cases, such as heart surgery, opioid-free surgery wouldn’t be an option,” Richards explained. “In all cases where opioid-free surgery is appropriate, it requires a willing surgeon and anesthesiologist, a compatible procedure, and above all a patient who wants an alternative approach and is motivated to follow an opioid-free operative course. It’s definitely a team approach. It’s been remarkable. Their pain is better controlled without putting them at risk.”