Much of the publicity today, as well as initiatives like the CDC guidelines, really focus on the outpatient problems with chronic pain patients. But there’s a growing concern with how we prescribe opioids for post-op pain control. There is a fair amount of literature that’s emerging about whether the way we prescribe opioids postoperatively is contributing to the problem. And it does appear that it is a big concern. The first thing to get across is that opioids are not the only way of controlling pain. We usually use multimodal analgesia, or rational pharmacotherapy if you want; a wide variety of other medications, adjuvant medications, gabapentin, acetaminophen, to try and reduce the amount of opioids that patients need postoperatively. We also use a variety of interventional techniques, such as epidurals, or peripheral nerve blocks to help with pain control. We even send some patients home with these peripheral nerve blocks, catheters that can help control their pain for as long as a week if they need it. Also, as we try to minimize the opioid burden, there needs to be an exit strategy. A lot of times patients get lost in the shuffle between surgeons and primary care physicians, and they’re left on opioids even a year out from their surgery. And so we need to be cognizant of that and make sure that they have some sort of an exit strategy.
Patients who are at high risk for opioid abuse and misuse after surgery are people who are young, as well as those who exhibit catastrophizing behavior, high anxiety, or depression. If they have high pain levels before their surgery, or if they’re already taking opioids before surgery at even minimal dosages, they’re at high risk for developing persistent use afterwards. We like to identify those patients before they get to surgery and develop a plan with them; have the conversations about their expectations and what we’re going to try to achieve, and then develop a multimodal, multidisciplinary approach to taking care of their pain postoperatively.