The Struggle To Treat Post-Operative Pain For Those With Opioid Dependence

By Paul Gaita 04/26/17

While there are guidelines on how to treat acute pain for opioid-dependent patients, post-operative pain treatment is still up in the air.

A post-operative male patient sitting on the bed in a hospital ward room.

When recovering from a post-operative procedure, opioid prescriptions are among the most frequently prescribed medications to help manage pain. A report published in JAMA found that 80% of patients who underwent surgery for relatively low-risk issues—carpal tunnel syndrome, gall bladder removal, or hernia repair—filled a prescription for an opioid pain medication within seven days of the procedure.

For people addicted to opioids, this can be a difficult and even life-threatening scenario—one that leaves both patient and medical professional with relatively few options.

A recent feature on NPR illustrates the challenges faced by both parties after a post-operative procedure. The subject of the feature, Max Baker, was a New England resident who became addicted to heroin throughout his teenaged years, and found help through the relapse prevention drug Suboxone.

Eventually, Baker weaned himself off that medication, and began to resume his life. But a 2016 car accident left him with a broken hand that required surgery; both Baker and his surgeon, Dr. James Shenko, was concerned that opioid use to treat post-operative pain would put him in danger, but the anesthesiology team cited research that showed a general success rate for the use of opioid painkillers on opioid-dependent patients who were using Suboxone.

The problem was that Baker had finished his Suboxone treatment. Soon after surgery, Baker approached Shenko for stronger medication. Faced with leaving his patient in unbearable pain or seeking out opioids in an illegal manner, he prescribed a small amount of Vicodin to Baker. Less than a month later, Baker was dead of a heroin overdose at the age of 23. There was no definitive cause for the relapse, but Shenko was left with the concern that other options were left unsaid. "What could you have done differently, what do you change? How do you treat patients like this?"

The problem faced by Shenko and many medical professions is that there are no clear guidelines on how to treat post-operative pain for opioid-dependent people. Both the Centers for Disease Control and the American Pain Society issued guidelines on how to treat acute pain in 2016, but no such instructions have been published that specifically address post-operative pain with non-opioid medicine.

Physicians like Dr. Shenko have noted that the ability to consult an addiction specialist would alleviate much of the guesswork involved in a situation like the one he faced with Baker. "Let's bring in a specialist in dependency and addiction into this equation, and let's manage it through that," he suggested.

Unfortunately, only 5,000 addiction specialists are currently available in the United States, and most are unaffiliated with any hospital, which makes them largely unable to help the nearly 2.5 million Americans addicted to heroin or opioids. But Dr. Sean Mackey, who heads the Pain Management Division at Stanford University, said that a "multidisciplinary approach" might provide doctors with additional tools to help their opioid-dependent patients. Prescribing non-opioid drugs, including non-steroidal anti-inflammatory drugs (NSAIDs), which includes aspirin and ibuprofen, in combination with psychological therapy and the possible use of Suboxone or methadone—both of which have analgesic properties—may provide a viable alternative.

However, Mackey also acknowledges that such a scenario is not always available to patients, as multidisciplinary approaches often require the resources of an academic medical center. The addition of more addiction specialists to medical facilities, and increasing access to relapse medication and treatment, appears to be the most viable solution for the moment.

Pain must be treated, whether the patient is addicted or not, according to Dr. Stuart Gitlow, a past president of the American Society of Addiction Medicine. "Whether he gets the opioids or not is less of the question," said Gitlow. "The biggest question is what to do to ensure this patient's safety going forward during the period for which he's experiencing pain?"

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Paul Gaita lives in Los Angeles. He has contributed to the Los Angeles Times, Variety, LA Weekly, and The Los Angeles Beat, among many other publications and websites.