Updated June 22, 2018
- Patient education is key to proper pain management.
- Opioids are just one piece of a comprehensive pain relief plan.
- There are several things patients can do to ensure they use pain medicines safely.
If you have been paying attention to the news, you know that America is in the midst of an opioid overdose epidemic. But if you think you need to avoid these powerful pain relievers completely, then there is more you should learn about them and about pain management in general. In fact, patient education, appropriate expectations about how your pain will be managed during and after surgery, and proper storage and disposal of medications after your surgery are integral components to a safe and effective plan as one prepares for surgery, says Steven Stanos, DO, medical director of Swedish Pain Services.
“We are in the midst of a cultural transformation around patient expectations related to pain management. In most cases during your hospitalization or procedure and afterwards, there will be some level of pain, and that in itself is not necessarily a bad thing,” says Dr. Stanos, who is also the immediate past president of the American Academy of Pain Medicine.
“The goal of pain management isn’t going to be to eliminate your pain but to decrease it as much as possible and as safely as possible so you can advance in your recovery and facilitate your post-operative rehabilitation. Unfortunately, the messaging around pain medicine use in the media and in some pharmaceutical advertisements all of us are exposed to on a daily basis has contributed to setting false expectations. The health care industry and medical community is working hard to provide more tools to patients and setting more realistic expectations about how one can safely and effectively manage pain and discomforts. The focus is shifting towards an emphasis on incorporating not just opioids or other types of analgesics but also the use of non-opioid approaches after surgery.”
How opioid use reached crisis level
The beginning of the opioid epidemic can be traced back to the 1990s, when there was an increase in prescribing those medications for not only cancer related pain but also acute and chronic non-cancer pain. The result of more aggressive prescribing indirectly led to a significant increase in unused pills, commonly left sitting in medicine cabinets. Those unused medications were ripe for misuse by family members, recreational drug users, and those struggling with addiction or misuse problems. In some cases, medicines were stolen and sold on the streets for non-medical use.
In a common scenario, a patient has elective surgery normally requiring one or two days of opioids to help manage their severe pain but is prescribed a far greater supply of pills —perhaps many times a supply needed for multiple weeks. Dr. Stanos says, “Besides the negative consequences of an increased supply of unused medications, a number of patients started on opioids for acute pain and, not being properly supervised, developed dependence and addiction problems over time. A very small percentage of those patients with addiction to prescription opioids moved on to more potent and dangerous illicit drugs like heroin and illicit fentanyl, and some of those people died from overdoses in the community.”
It’s worth noting, Dr. Stanos adds, that prescription opioids are only part of the issue. In fact, at a national and state level, the number of prescriptions prescribed medically has gone down consistently over the past five years, as have deaths reported related to prescription opioids. Unfortunately, the opioid overdose numbers continue to increase markedly. The main cause is now overdoses related to heroin and illicitly manufactured drugs such as fentanyl and carfentanil coming into the US illegally from foreign countries. These drugs are far more powerful and potent than prescription opioids and are causing a growing number of overdoses and deaths by substance abusers and people with active addiction disorders.
When it comes to the prescription opioid crisis, the medical community has been active and has put forth several initiatives to counteract the addiction and overdose problem. In 2016, the Centers for Disease Control and Prevention came out with guidelines that recommend safer prescribing tactics for how opioids can be prescribed for acute pain. Some insurers will only approve prescriptions for a limited time period such as three to seven days. In Washington and other states, legislators are in the midst of rewriting the state medical board laws for pain management with an emphasis on improved safety and monitoring.Though the process isn’t complete, Dr. Stanos says the new rules will probably include:
- A seven-day to 14-day maximum supply on opioid medications for prescriptions when people are leaving the hospital after surgery, unless the physician makes a specific explanation in the medical record.
- Encouraging the integration of other types of pain reduction methods aside from opioids, including non-opioid medications and other therapies (i.e., physical therapy, counseling, exercises, and procedures).
- Increasing the number of take-back programs where people can safely return unused medications in the community to be destroyed at specifically designated pharmacies, receptacles, and law enforcement agencies.
- Appropriately screening patients prior to surgery to determine their potential risk for problems with pain medication use, including addiction. Dr. Stanos notes that most patients who are prescribed pain medicine and monitored appropriately are at low risk for developing an addiction disorder. Some patients may be at greater risk based on a personal or family history of addiction or substance misuse, genetic factors, and psychosocial problems. Close monitoring and education is critical.
- Developing ways to more closely re-assess patients after surgery and get them back into the physician’s office for close follow up.
In Washington state, the pain rules, which are being realigned to match the CDC guidelines, have already been approved in House Bill 1427 and are now being finalized by the state’s medical boards. The new rules are scheduled to go into effect January 1, 2019.
How to use opioids safely for pain managementIf you are concerned about possible negative consequences, you can draw some assurance that action is being taken to ensure proper prescribing of opioid medicines. To further ensure safe use of pain-relieving opioids, there are other steps you can also take, Dr. Stanos says.
- Communicate with your health care provider about any pain you feel and how it impacts your daily function. “Besides just reporting on your level of pain, are you more sad, depressed or anxious? Are you not sleeping well? A broader report on how pain is impacting your life and daily activities should be part of a proactive discussion you have with your health care team,” Dr. Stanos says.
- Before surgery, ask what the plan is for therapy and medical management afterwards. Besides physical therapy or occupational therapy, are there other behavioral medicine interventions, like counseling, mind-body techniques, deep breathing, or stress management that may also be available?
- Know potential side effects and be careful to monitor them. If there are any side effects, the health care provider should be notified as soon as possible to discuss other options.
It’s important to remember that pain is an important signal and warning sign for the body, Dr. Stanos says. “You always want to be aware of the pain and its course over your recovery. If the pain is lasting longer than it should or is increasing, there may be something that needs to be reassessed by your health care team. An increase in pain could be the sign of an active infection or other medical complication.”
And of course, it’s crucial to take the medicine properly. Misuse of opioids can include taking too much of the medicine, which can cause problems thinking clearly and toxicity such as lethargy and respiratory depression (trouble breathing). All of these are possible early signs of overdose. Also, it’s important to follow dosage directions. Make sure you understand how frequently the medicine should be taken, how many hours it provides pain relief, how it affects the body, and what purpose it serves in the treatment plan.
You should also be aware that opioid use should not be synonymous with pain management. “With good quality multimodal care, opioids if appropriate may be just part of a more comprehensive pain management plan,” Dr. Stanos says. Other pain relief medications that could be prescribed along with or instead of opioids include anti-inflammatories, anticonvulsants, and topical analgesic patches. In some cases after surgery, take-home infusion devices may be used where the pain medicine and numbing medicine is delivered slowly to your body via a catheter for one to two days without the need for oral medicines. Whatever the medication plan, you should clearly understand the role each type of medicine plays in your recovery. Dr. Stanos also recommends having a family member sit in on this discussion with you and your physician so someone else understands what the plan is and can make sure you are taking the medicines properly.
In the end, opioids are not a miracle cure or the only option to control your pain. Opioid medicines aren’t to be entirely avoided either. What you want is a pain relief plan that will help you best manage and get back on your feet as fast as possible. “Opioids can be helpful for some types of pain but not all,” Dr. Stanos says. “The goal of the medicine is to help decrease the pain so you can be more active, participate in therapy, and suffer less as you recover. Understand that no single medicine will take the pain completely away. Safe options exist for a plan specific to your needs and circumstances.”
Do you have questions about your prescription painkillers or other medications? Contact your doctor or a health provider at Swedish Pain Services today. Learn more about pain management while recovering from major surgery.
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This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.