Turning the Tide
By Nicholas Pulos, MD
I was fortunate to train as our profession’s and the public’s perception of pain management was changing for the better. As an intern, I rounded on hip and knee patients prescribed morphine PCAs post-op. I remember my mentors telling patients (erroneously) that the risk of opioid addiction was low because they had had surgery. Things changed after one of the young attendings returned from Tanzania with reports of performing total joint replacements using only acetaminophen for postoperative pain. By the end of residency, we were employing a multimodal regimen which included NSAIDs, acetaminophen, gabapentin, sleep agents, and short- and long-term oral narcotics in addition to regional anesthesia, anti-nausea agents and psychosocial interventions. It was a revolution.
As a fellow, we read the paper by Johnson et al. in journal club which reported that 13.5% of opioid naïve patients continued to refill their opioid prescription between 90 and 180 days following elective hand surgery. Thus, one of the most frequent complications following our most common procedures was opioid addiction, far eclipsing nerve damage, recurrence, wound complications and infection. I was determined to start practice without providing opioids for these surgeries.
In my practice, I tell patients up front that I don’t prescribe opioids for routine procedures such as carpal tunnel release. I often paraphrase the Johnson study. Aided by news reports in the lay press about the opioid epidemic and the President declaring it a public health emergency, the vast majority of patients are understanding, if not grateful. I counsel my patients that surgery is not painless; they will have some discomfort for the first two nights, but after that, the pain will abate. I encourage patients without other comorbidities to alternate acetaminophen and ibuprofen for relief. At the first post-op visit for suture removal I ask them about their pain and find that indeed the first two nights were uncomfortable, but tolerable.
Recently, several groups have put out randomized controlled trials supporting the use of anticipatory guidance and the efficacy of non-opioid pain regimens following elective soft tissue procedures in the hand and wrist. Out of this tragedy, surgeons have been inspired to put out high quality level one evidence in the hand surgery literature. These studies support what I have seen in my short time in practice. I am grateful to have trained when I did and to have started my practice as the tide was turning on opioids.
Johnson SP, Chung KC, Zhong L, Shauver MJ, Engelsbe MJ, Brummett C, Waljee JF. Risk of prolonged opioid use among opioid naïve patients following common hand surgery procedures. J Hand Surg Am. 2016;41(10):947-957.