Surgeons are reducing patients’ need for prescription opioids after surgery by educating them about non-opioid alternatives.

When Dr. Richard Blondell first started practicing medicine 40 years ago, many of his patients approached pain with an “I can tough it out” attitude.

Even when they broke a bone or needed surgery, they’d turn down a pain medication with the prescription opioid called codeine.

The medication has been around since the 1950s, but patients were concerned about its addictive potential.

“People didn’t want those drugs because they thought they’d get hooked,” said Blondell, professor and vice chair for addiction medicine at the University at Buffalo. “Plus, tolerating pain in the World War II generation was just part of the deal.”

In the 1990s, with the increasing availability of prescription opioids — and heavy marketing by pharmaceutical companies making those drugs — pain became something to control at all costs.

But with drug overdose deaths from prescription opioids rising to over 17,000 in 2017, some surgeons are trying to shift patients’ expectations about the best way to manage pain after surgery.

“The goal of medicine is not to relieve every bit of pain,” said Blondell. “The goal is to make pain tolerable.”

This is being accomplished by educating patients about alternative methods of managing pain and by using prescription opioids only when absolutely needed.

The big question is whether patients will manage “toughing it out” like earlier generations did.

A new study suggests that, in many cases, the answer is yes.

In the new study, a group of researchers at the University of Michigan found that when people undergoing surgery were educated about non-opioid pain relief options, more than half of them used no prescription opioids after their procedures.

In addition, almost all patients reported that their pain was manageable, even without using opioids.

The study was published online May 30 in the Journal of the American College of Surgeons.

Researchers enrolled 190 people in the study who were undergoing one of six surgical procedures: gallbladder removal, hernia repair, removal of the thyroid or parathyroid gland, prostate surgery, sinus surgery, or a surgical weight loss procedure on the stomach.

Before the surgery, clinic staff counseled patients about how to manage their pain without the use of prescription opioids.

This included taking alternating doses of acetaminophen and ibuprofen every three hours during the day and night to provide continuous non-opioid pain control.

Patients also received a small “rescue” prescription for opioids in case the non-opioid drugs weren’t cutting it. The size of these prescriptions ranged from 4 to 10 pills, depending on the procedure.

Among the 48 percent of people who did use opioids after surgery, the average number of pills used was four and the average number of pills left over was two.

Surgeons aren’t the only doctors to prescribe opioid pain medications. But between 2010 and 2016, new opioid prescriptions by surgeons increased over 18 percent.

Overprescribing can increase the risk of opioid misuse and addiction by patients. It also increases the chance that unused pills will be diverted — misused by other family members or stolen and given to other people.

Blondell said, “surgeons have an important role in helping to keep prescription opioids from being diverted to the illicit marketplace.”

Concerned about the opioid epidemic, some physicians have started programs aimed at decreasing opioid use among patients after surgery.

Dr. Maisie Shindo led an initiative at Oregon Health & Science University (OHSU) in Portland, Oregon, to reduce the use of opioids among patients undergoing surgery at her center.

As a result, more than half of patients who had their thyroid or parathyroid glands removed went home with no prescription opioids at all.

“The majority of patients didn’t need opioids,” said Shindo, surgical director of the Thyroid and Parathyroid Surgery Center at OHSU. “They did OK with medications like acetaminophen and ibuprofen, ice packs, and sore throat medications for thyroid procedures.”

The results of her team’s effort were published last December in the journal JAMA Otolaryngology-Head & Neck Surgery.

Although these opioid-sparing programs, as they’re called, can shift patients toward alternative pain management methods, the goal isn’t to do away entirely with prescription opioids.

“We also want to make sure that patients sitting at home are comfortable,” said Shindo.

But studies like Shindo’s show that many patients can do well with only a small number of opioid pills — or even none.

A big part of these programs is surgeons talking with patients about what pain after surgery — or discomfort, as Shindo prefers to call it — will be like.

“It really depends on the expectations that are set with the patient ahead of time about how the pain is going to be managed,” said Shindo. “This also includes explaining to patients that they are going to have some discomfort.”

Shindo suggests that patients ask their surgeons these questions before surgery:

  • What’s the pain going to be like after my procedure?
  • How are you going to manage my pain?
  • Is there a way to manage the pain without using prescription opioids first?

Blondell said, “patients who have concerns — especially those with a personal history of alcohol or drug problems — should ask their surgeons before surgery about opioid-sparing alternatives for postoperative pain management.”