With growing concerns about opioid addiction, many people are leery of taking these drugs after surgery. But even though prolonged pain during the recovery period can lead to an elevated risk of chronic opioid use, that’s no reason to put off or avoid an operation, say the authors of a new study by the Stanford University School of Medicine that looked at opioid dependence in more than 640,000 post-surgery patients.
Overdose deaths involving prescription opioids — drugs such as OxyContin, Percocet and Vicodin — have quadrupled since 1999. Efforts by doctors to improve pain management have had the unintended consequence of propelling an epidemic of addiction, overdose and death from these medications that has now expanded to include heroin and fentanyl, the drug blamed in the death of music icon Prince.
The researchers at Stanford wanted to determine whether taking opioids after surgery may be the risk factor that starts people on the path to chronic use or abuse.
First of Its Kind Research
The study looked at the potential for chronic opioid use among patients undergoing 11 of the most common types of surgery, such as knee and hip replacements, gall bladder removals, C-sections and appendix removals. Although previous studies have uncovered opioid abuse after surgery, no studies had looked only at people who hadn’t used prescription painkillers in the past. “We wanted to know if there was this same risk for people who aren’t using opioids when they come in for surgery,” said study author Dr. Eric Sun, an anesthesiologist and instructor at Stanford, in a statement. “Are they at higher risk for using opioids longer term?”
In a word, yes. The study found that knee surgery patients who hadn’t used opioids in the past were at the highest risk of long-term opioid use; they were about five times more likely than a control group to chronically use opioids. Gall bladder patients had the next-highest risk at three-and-a-half times greater than people in the control group.
Other factors that increased the risk of opioid dependence after surgery included being older than 50, having a history of drug abuse or depression, and the use of benzodiazepines or antidepressants. The study was published July 11 in the journal JAMA Internal Medicine.
But the researchers were quick to put their findings into perspective.
“The message isn’t that you shouldn’t have surgery,” said Dr. Sun. “Rather, there are things that anesthesiologists can do to reduce the risk by finding other ways of controlling the pain and using replacements for opioids when possible.” Among those alternatives is the use of nerve blocks after surgery to limit or avoid altogether the use of opioid painkillers and prescription drugs, he said.
Non-Drug Pain Relief
Study co-author Beth Darnall, PhD, said that, ideally, chronic pain should be treated without opioids. She emphasizes alternate methods of pain management that help calm the nervous system such as diaphragmatic breathing, physical therapy and mindfulness meditation.
“We hope that by optimizing patients’ psychology — and giving them skills to calm their own nervous system — they will have less pain after surgery, need fewer opioids and recover quicker,” Darnall said.
Alternative therapies are particularly important for people in recovery from the abuse of alcohol or other drugs. But even for those whose addiction risk is low, opioid pain relievers don’t always make pain go away. Patients can develop a tolerance to the medication and, over time, their pain may actually get worse. It’s a phenomenon called opioid-induced hyperalgesia and studies on animals have shown it occurring after only a single, high dose of opioids.
A multidisciplinary approach is key in treating pain in people with substance use issues. A combination of psychological counseling, either in a group or individually, as well as physical and occupational therapy can help manage pain. In terms of medication, non-opioid drugs such as anti-epileptic drugs, antidepressants and anti-arrhythmic drugs can be effective. Anti-epileptic drugs calm nerves, which can help relieve burning, stabbing and shooting pain. Antidepressants are also used in treating long-term pain because they help regulate pain signals, while anti-arrhythmic medications have been shown to relieve headaches and nerve pain.
Intriguingly, lab tests have indicated that simply directing a person’s attention away from the pain can be comparable to giving them a dose of morphine. “It actually has a very powerful effect, and we look at the brain and we see the pathways that are involved, so it’s not just that the person feels the pain and just ignores it,” Dr. Catherine Bushnell, director of the National Center for Complementary and Alternative Medicine at the National Institutes of Health, told Managed Healthcare Executive. “It actually diminishes it.” Other research shows that people who have practiced yoga long term have higher pain tolerance levels.
Stanford researcher Dr. Sun said surgery “may unmask an individual’s susceptibility toward long-term opioid use” but that the overall increase in risk in no way suggests that people skip surgery. Rather, he said, the study results should serve as a warning to physicians and surgeons to keep a keen eye on their patients’ opioid use after surgery.