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 Volunteers in the study underwent one of six minor surgeries:
laparoscopic gallbladder removal, laparoscopic repair of a groin
hernia, removal of the thyroid or parathyroid gland, robot-assisted
removal of the prostate, endoscopic sinus surgery, and a type of
weight-loss surgery called laparoscopic sleeve gastrectomy.
Before the surgery, the 190 volunteers received counseling on pain
management and were advised to take a non-opioid pain reliever every
three hours, alternating between 600 milligrams of ibuprofen and 650
mg of acetaminophen.
Researchers also gave patients a small prescription of 5-mg pills
containing the opioid oxycodone, counseling them to take the
narcotic only if their pain was unmanageable.
When researchers contacted the patients one to three months after
the surgeries, they learned that 52% hadn't used any opioids at all.
Among those who did use opioids, 98% used no more than 10 pills and
almost all agreed that their pain was manageable under this regimen,
the researchers report in Journal of the American College of
Surgeons.
"Over the years, surgeons often prescribed 20 to 40 oxycodone
tablets after many procedures. This study and others like it suggest
that those quantities were not necessary in many cases," said Dr.
Kevin Hill of the Harvard Medical School in Boston, who was not
involved in the study.
"The efficacy of this protocol is more about expectation setting,
education and using non-opioid pain medications which are very
powerful," coauthor Dr. Chad Brummett of the University of Michigan
Medical School in Ann Arbor told Reuters Health by phone.
"The fundamental concept is that we as surgeons and dentists are
gatekeepers to opioid exposure," said coauthor Dr. Michael Englesbe,
also of the University of Michigan. He noted that most heroin users
and people at risk of overdose got their first exposure to opioids
from a medical care provider.
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Up to 10% of patients who take opioids for the first time after an
operation develop long-term dependence, and this risk of dependence
has been found to be associated with the size of the initial
prescription, the researchers wrote.
Prior studies have also found that patients tend to have about 19
leftover pills after their recovery. In the current study, half the
patients had no more than two pills left over from the small supply
they had been given.
Excessive prescribing of opioids increases the risk of prolonged use
and results in leftover pills getting diverted and being abused by
others, especially adolescents.
In 2017 in the U.S., an estimated 11.4 million people aged 12 or
older had misused opioids in the past year, according to data from
the National Survey on Drug Use and Health.
The study results prove that many surgery patients don't need
opioids to manage pain and that use of these painkillers needs to be
de-emphasized where possible, said Beth Darnall, a pain researcher
at the Stanford University School of Medicine in California, who
also was not involved in the study.
"That said, some patients absolutely need opioids, and we need to be
mindful of this variability," she added.
Brummett and Englesbe and their colleagues acknowledge in their
report that this approach "might not be appropriate for more complex
procedures." Going forward, they hope to learn more about its
feasibility across multiple surgical procedures and across a diverse
patient population.
"It will be important to understand the patient characteristics that
favor the use of this pathway," they conclude.
SOURCE: https://bit.ly/2IfWeid Journal of the American College of
Surgeons, online May 31, 2019.
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