Ohio State University anesthesiologist Michelle Humeidan, MD talks about avoiding opioid overdose after surgery by properly preparing before, during, and after surgery.
Interview conducted by Ivanhoe Broadcast News in 2022.
There has been a move away from opioid use. For a lot of us, it’s the obvious reason. Can you tell me why some physicians are starting to move away from that prescription?
HUMEIDAN: I think fundamentally we’ve just realized that opiates actually aren’t necessarily the best and perfect way to manage pain. They certainly have their limitations and their downsides. We are all aware of the opiate crisis and the addiction risks and misuse risks of giving our patients opiates. They also don’t make people feel that great. They’re excellent pain relievers, but they have other side effects. Itching, nausea, vomiting, constipation, respiratory depression. All of those things really impair how patients recover after a procedure or surgery or an injury that they would be given pain medication for. If we limit the opiates, hopefully we’ll have patients feeling better without those side effects. Then they can get back to their baseline or recovered quickly. Of course opiates still have their role, but we’re just really recognizing that going to them first and in abundance and not using other options is probably not the best way.
So changing that school of thought for pain management, is that a tough thing to do? This has been a longstanding way of controlling pain for patients.
HUMEIDAN: It’s tough for several different reasons. One is everyone is comfortable with opiates. You give them and you can expect a certain amount of pain control and relief somewhat predictably. It’s an easy thing. You give an injection in the IV or you give up a medicine by mouth or some other route and you get your effect. When you’re doing a multimodal approach, there’s often many pieces to that, so it’s not as simple as one intervention or one medication. You’re trying to target different ways that pain can be relieved. It’s not just the opiate relief, but there’s other mechanisms of pain that we can effect. It’s more complex in the sense that more interventions, more pieces to that, that management plan. Part of it too, I think is dealing with expectations of patients. Sometimes I think if the patient really expects they’re going to have zero pain or no pain or that it’s going to be without these side effects. We want everyone to be happy with their care and satisfied with the way they’re being managed and be part of that. I’m trying to recalibrate the expectations so that it might take a little longer to manage your pain or maybe you’re okay with mild pain versus no pain. Those types of expectations are important as well.
Can you speak about the multimodal approach little bit? How do you start?
HUMEIDAN: It’s really simple actually. Even though there’s a lot of options and the more options you incorporate into your plan in theory, the better your pain relief will be. The individual options themselves are pretty straightforward. It’s things like acetaminophen, NSAIDs. We’re using regional blocks if there’s a way to numb up the nerve or the area of the body that is the source of the pain. You can use steroids and other types of nervous system modulators. There’s a lot of options and picking what’s right for the patient, is something that requires some tailoring and some details on their history and the type of pain that you’re planning to have to manage. All things together, it’s not difficult to make the change. You just have to be willing to give it a try and educate your patients and help them know what to expect.
Would patients start preparing before surgery?
HUMEIDAN: Yes.
Can you talk about that?
HUMEIDAN: There is two major classes of patients. There’s the patient that comes to surgery that’s opiate naive. Then there’s the patient that comes that’s opiate tolerant or have been on opiates for some time. What we have focused on so far is really the opioid naive patient and doing things like getting them really involved in the discussion of what to expect around their pain management and just setting those expectations. That work is done in advance of surgery. It’s really important to make sure they understand what is going to happen, what they can do to participate in their pain management, and what things will be done if things aren’t going the way they expect. Some of that reassurance is really important. They can also start taking medication at home and advance of the procedure like acetaminophen is one of the ones that we use. We can load that up in the system in the day or so before surgery. Then that helps us have to give less opiates for their pain control. These things are done before surgery even starts.
Then there are measures taken during surgery?
HUMEIDAN: Right. In the operating room, we can use the blocks that I talked about where we use numbing medicine to directly inhibit the pain transmission to the brain or the spinal cord. We can also use other adjuncts that are given in the IV that are non opiate based. We even have NSAIDs that we can use that way as well. Depending on the situation, there’s usually at least two or three adjuncts that you can consider in the operating room to help minimize the opiates needed.
Then what happens when the patient is on their own? We discharge them and they’re on their own managing their pain. What are their options at that point?
HUMEIDAN: They also have many options. It can include pharmaceutical things like, acetaminophen, Ibuprofen, things they can take by mouth. There’s patches. Lidocaine is a local anesthetic patch. Other types of interventions like heat, ice, elevation, those types of things, those can’t be underestimated. In conjunction with other approaches, they can be a part of a very effective pain management plan. I think talking with the provider from the patient perspective of what they should be doing when they go home, is really important, knowing the steps to take. I think the number one thing patients can do is stay ahead of their pain. Don’t wait until you’re in some degree of agony before you start your pain management plan. Be proactive. I think that that helps you not get behind and allows you to have a better effect from non opiate strategies and really saving those opiates for the pain you just can’t control otherwise.
I was going to say this is not a complete elimination of opiates or in some cases, can people be free of pain without the opiate?
HUMEIDAN: There are cases where you can avoid it altogether. It really depends on the situation. So we’ve had a few different types of surgery at Ohio State and The James where the routine management was to give patients opiates after surgery and there’s a percentage of those patients now that don’t need them because they’re getting all of these other adjuncts and it’s really a testament to how well they’re working. We still use opiates, but they are for the backup plan, they’re breakthrough pain. We try not to go to them as our first line or even second line, further down so that we can maximize the non opiate approach.
What are some of the benefits of a patient not having the reliance on the opiates?
HUMEIDAN: Many different things. The benefits right off the top are pretty much feeling better and having a faster recovery. If you are taking opiates, the side effects are very common. A lot of patients can have nausea, they can have itching, they can have respiratory depression, which is more severe urinary retention. Constipation is a really important one. None of those things make patients feel very well and want to eat, want to get up and move and work toward their goals to go home or to be back to their baseline if they are already home. Getting rid of the opiates altogether if that’s possible or really minimizing them as much as possible helps those side effects not be as big of a player in how the patients are recovering. That’s the main thing. The main benefit is the recovery overall is better and higher-quality and faster. I think also, not having opiates go home with patients or in smaller amounts minimizes the community risk at large, but also the risk to that patient for developing misuse, abuse and diversion. I think that they feel better and they recover better, but there’s also a bigger public health benefit to putting less opiates out into the community for the care of our patients.
I know you and your team had studied this quite a bit. Was there cost-savings too?
HUMEIDAN: There is a cost savings. It depends on how you look at it. There’s a direct savings when it doesn’t take as much hospital resources or time to care for a patient after a procedure. There’s also opportunity savings. Meaning that if someone’s not in the hospital then their spot is available for a different patient that needs to come in and get care. That is particularly important these days with the pandemic and all of the things that are really putting a lot of stress on hospital resources. If we can open up beds because people are doing well enough to go home faster than they used to, that’s an exceptional reason to do this work as well.
How much faster is the discharge on average?
HUMEIDAN: It depends. We’ve had a few procedures where we’ve shaved an entire day or two off the length of stay. Those were procedures that would typically require a four to seven day hospital stay. We’ve also shaved their hospital stay off altogether where we used to have patients that would require an overnight stay or two that are going home now after surgery. You have to pick the right patient, the right situation, and all of that, but it’s definitely possible and minimizing opiates and having a good pain control plan contributes to that a lot.
Anything I didn’t ask you that you would want to make sure people know?
HUMEIDAN: I think to not be afraid to have a good discussion with your provider about your pain management plan. I think getting those expectations set in advance is really important. Some of the best minds and pain management and societies have come together in the last year or two and put out some recommendations about how the provider and the patient should discuss things and doing that discussion in advance of an anticipated painful experience is important. Reassuring the patient that they’re going to have options if they’re not satisfied is also really important. It’s a team effort I think is important. So I just want folks to engage with their providers so that everyone can work together.
I just wanted to ask you two more questions more for my clarification, and for my writing purposes. What are some of the procedures where traditionally it’s either where the incision is made or the type of procedure where that pain is really at a level where patients will really need to stay ahead of it. Are there some areas that are more painful than others to recover?
HUMEIDAN: Absolutely. Especially painful procedures might include total joint arthroplasty, abdominal surgery of any kind, and lung surgery or thoracic surgery of any kind. Those are at the top of my list of very painful procedures. Of course there’s pain associated with all of them. But those those in particular, if you can be proactive, good things can be gained from that.
Can you name off what some of the common opiates are again.
HUMEIDAN: Some of the common opiates that we really are using a lot less of would be medications administered in the IV like morphine, hydromorphone, which is commonly known as Dilaudid. Fentanyl, of course. Those are IV medications that we’re really using a lot less preoperatively. Then oxycodone is one of the common oral opiates that patients get prescribed postoperatively and we’re minimizing the use of that as well.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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