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In Surgical Care, Opioid Use Is Complex

M. Sophia Newman, MPH

M. Sophia Newman, MPH

March 6, 2024


On Memorial Day weekend in 2015, Travis N. Rieder, PhD, a bioethicist at Johns Hopkins University in Baltimore, Maryland, hopped on his motorcycle. He didn’t know it, but the brief ride would change his life.

A few blocks from home, his motorcycle and a van collided. Tumbling to a stop on the asphalt, Dr. Rieder knew that his foot was badly injured; wrestling his mangled boot off a moment later brought a wave of intense pain. Rushed to the ER, he soon learned the foot might require amputation. Over the next months, he cycled through three hospitals and six operating rooms, receiving surgical care that ultimately kept his foot intact. But before all that could begin—before, in fact, his ambulance left the accident scene—he had his first encounter with a drug that would raise difficult questions he later strove to answer.1

“What came to define my medical trauma for me was the process of withdrawing from opioids,” Dr. Rieder said.

His experience ultimately revealed a serious gap in surgical care: insufficient assistance for patients discontinuing their use of prescribed opioid medications. As the US continues to confront its long-running, highly complex opioid epidemic, engaging surgeons and other clinicians in ameliorating this painful and potentially deadly treatment gap may be an essential next step.

“Looking back now, what I really identify as the problem is that not that opioids were used aggressively, but that they were used without a plan.”

Dr. Travis Rieder

“Causing an Accident and Leaving the Scene”

The use of medications to manage Dr. Rieder’s pain was initially unremarkable; his level of pain was extreme, and opioids are a standard treatment option. But as his care progressed from acute to reconstructive phases, his opioid use increased, titrated upward by alternatively sympathetic and reluctant clinicians, until he was taking about 200 mg of morphine equivalent, plus gabapentin, each day.

“Looking back now, what I really identify as the problem is that not that opioids were used aggressively, but that they were used without a plan,” he said.

After 2 months of care, a clinician pointed out that Dr. Rieder’s opioid use should have already ended. Dr. Rieder quickly committed to cessation but struggled to find advice on how to do it safely. On one physician’s recommendation, he finally cut his dosage in quarters, dropping one-fourth of the total per week. This taper brought on withdrawal symptoms of unbearable severity: “I had just had my foot blown apart. I had just had all these surgeries. I had just had unanesthetized cauterization of my foot. You know, I had just been through a version of hell. And yet every moment in withdrawal was the worst moment in my life.”

Searching for a clinician who could advise him on how to manage his agonizing withdrawal, Dr. Rieder was alarmed to find no such person. One physician said he was out of his depth. The inpatient pain management team that had dramatically escalated his opioid therapy after one of his surgeries was unwilling to speak to an outpatient. Addiction medicine was limited to patients who had been using opioids for far longer than a couple of months. The sole follow-up advice came from the doctor who’d provided the tapering plan, who eventually advised returning to his full dosage and “trying again later.” Fearing he would never achieve cessation, Dr. Rieder instead trudged through a successful, albeit miserable, withdrawal.

Afterward, he refocused his career in bioethics on an important question: why were a dozen clinicians able to prescribe him opioids, but not one able to assist him in discontinuing them? “Prescribing opioids and then leaving patients to fend for themselves is not merely ‘not helping,’” he wrote in In Pain: A Bioethicist’s Struggle with Opioids, his 2019 book. “It’s causing an accident and then leaving the scene.”1

Well-reasoned yet bristling with emotion, In Pain and Dr. Rieder’s 2023 John J. Conley Ethics and Philosophy Lecture at Clinical Congress examined the complexities of opioid withdrawal and the nationwide structural issues underlying this treatment gap, articulating an obligation for physicians to do better.

Change on a National Scale

What is notable about prescription opioid use in the US today is that physicians, by and large, are doing better. The high tide of the epidemic saw excessive prescription rates—for example, from approximately 2 million opioid prescriptions to Medicare beneficiaries in 1991 to approximately 41.6 million such prescriptions in 2015.2 But those rates have now sharply decreased nationwide—in the case of Medicare beneficiaries, to approximately 19.1 million prescriptions in 2019.2 A 2024 Journal of the American College of Surgeons study showed that declines in rates of surgery-related opioid prescribing occurred in 81.6% of US counties between 2013 and 2017.3

This change has come as the pendulum of culture has swung from cavalier attitudes about opioids to deep concern. Across the US, healthcare centers have implemented programs meant to oversee, standardize, and reduce opioid prescribing. Although a few doctors persist in giving extraordinarily large opioid doses,4 most of the epidemic’s ravages (including increases in its toll of more than a half million opioid-related deaths5) now come from illicit, not prescribed, drugs.

That said, few expect that opioid drugs will be eliminated from use. They are an effective, well-known, accessible pain management method, available in multiple fast-acting and extended-release formats, often at comparatively low costs—in other words, an option difficult to replace or forgo. Seth Waldman, MD, director of the Division for Pain Management at the Hospital for Special Surgery in New York, New York, said, “Our goal is to make sure that we’re using opioids when they’re necessary at the lowest possible dose for as short a period of time as possible, but also to make sure that people aren’t avoiding opioids when they’re necessary—because they are. They’re important drugs, still.”

Tapering Safely

However, right-sizing opioid prescribing does not directly amend the problem of absent support for opioid discontinuation. Here, the need for care is significant. Guidelines from the US Department of Health and Human Services (HHS) and the US Centers for Disease Control and Prevention, updated in 2022, state that patients tapering opioid therapy face “clinically significant risks, particularly if opioids are tapered rapidly or patients do not receive effective support.”6

These risks extend beyond the physical pain, gastrointestinal symptoms, depressed mood, and ruptured trust in clinicians that Dr. Rieder described. Unassisted opioid cessation also can result in suicidal ideation and self-harm, while failed tapers increase the likelihood of addiction and patients seeking drugs from high-risk sources. In addition, patients returning to a higher dose of opioids after a failed discontinuation attempt risk experiencing overdose as a result of decreased tolerance to the drugs.

Avoiding these outcomes requires shifts in patient care—including helping clinicians understand how to taper and when.

In October 2019, HHS also published a brief guide for clinicians on appropriate dosage reduction or discontinuation of long-term opioid use.7 It conveys important considerations for tapering, including considering the complicating presence of depression, anxiety, and post-traumatic stress disorder, as well as opioid misuse symptoms or opioid use disorder. Rather than the 25% reduction in dosage per week Dr. Rieder underwent,1 the guideline advises a reduction every 4 weeks of 5% to 20% of the dose the patient is consuming at the start of the taper, with slowdowns in the decreased amount if withdrawal symptoms require.7 This estimated rate converges with Dr. Rieder’s own recommendation of roughly 10% per step.1

Clear advice on tapering is already common practice at some hospitals. Per Dr. Waldman, the Hospital for Special Surgery has designed a tool for modifiable opioid tapering and integrated it into the hospital’s electronic health records.8 It permits clinicians to autogenerate a calendar for patients who are ready to taper off opioids used for acute perioperative pain. The schedule shows what dosage to take at what date and time and can be tailored to a patient’s reduction goal and other factors. Dr. Waldman noted that, while a dosage reduction of 5% to 20% per step is possible, the rate of decrease could be faster than 20% because the tool is primarily for patients not experiencing long-term opioid use.

Following Up While Tapering Down

While prescribing or administering opioids may take seconds, discontinuing usage can take many months—and per HHS, clinical follow-up with these patients may be required as frequently as once per week.6 As a result, the surgical team that prescribed opioids for perioperative pain are not necessarily the correct healthcare professionals to follow up with the same patient through the process of tapering.

While surgeons should nonetheless know the basics of opioid cessation, the question is, who should do this work? To phrase the issue as Dr. Rieder did: “We need somebody to own the patients long-term right now. At almost all these centers, nobody owns these patients long-term.”

In his Clinical Congress lecture, he proposed assigning mid-level clinicians on surgical teams the responsibility of offering easily accessible support to patients through opioid withdrawal.

This approach is already in practice at some hospitals. Lourdes Castañón, MD, FACS, a trauma surgeon, directs a burn program at the University of Arizona in Tucson, where patients needing burn care receive pain management in acute and longer-term contexts. “We have an open access clinic,” she said, where a multidisciplinary team offers frequent follow-up of patients after discharge. “Since we follow them on a weekly basis, we’re able to monitor their pain and start weaning them off from there.”

Dr. Rieder worried that the frequent, long-term follow-up with a patient discontinuing opioids may be a money loser for healthcare facilities. “The financial incentive is not to have the extra appointment.”

But Dr. Waldman raised the idea that the economics of not serving patients as they withdraw from opioids is a false one. “Not only is it good to provide these services, it is ultimately in the financial and administrative interests of the hospital to do that. Every bad outcome has a cost associated with it. When patients are dissatisfied, they are liable to sue. Patients who have additional complications are liable to stay in the hospital longer than they otherwise would. If you take all the money you would spend on those things and instead spend it on having someone evaluate and treat those patients properly with regard to pain medications, you’ll end up saving money by doing the right thing.”

Starting with the End in Mind

Dr. Waldman’s comment underscores that the best patient outcomes depend on clinical foresight that aims to avoid risks—an obligation that may fall squarely on a surgeon and his or her team.

Some of this foresight is focused on a shift away from opioids entirely, which obviates managing difficult opioid withdrawal. This is underway across the healthcare environment. Dr. Castañón, who spoke at a session on burn care at Clinical Congress 2023, described a strong emphasis in her department on using regional anesthesia in lieu of opioids. “When we use regional anesthesia intraoperatively, our patients require a lot less anesthesia, a lot less narcotics during the procedure,” she said, adding that the same technique can then fully obviate the need for opioids during postoperative inpatient care.

In addition, Dr. Castañón said, “With early intervention and physical therapy massages, you’re able to get that wound stretchy and not as congested, and it requires a lot less pain medication. We’re able to get patients to a point where we’re actually able to wean them off pain medication completely.”

Beth Darnall, PhD, who directs the Pain Relief Innovations Lab at Stanford University in Palo Alto, California, has innovated in this mode as well. “I would say the one piece that’s really crucial is that we provide education around how people can best control their pain,” she said.

In addition to helping individual patients slowly reduce their opioid use, Dr. Darnall has developed a proactive patient education program called Empowered Relief, which offers one-time, 2-hour sessions on pain relief skills for perioperative patients and people with chronic pain. The program has now certified 1,100 clinicians in 27 countries. “If you go to the Cleveland Clinic for spinal surgery, you will receive Empowered Relief before or after surgery,” she said.

The program has generated evidence in clinical trials that it reduces pain levels and painkiller use, even though it does not mandate ceasing or avoiding use of any drug. “We don’t direct people to use less opioid medication” as part of the program, Dr. Darnall said, but rather provide skills that may reduce the need for medication-based pain relief.

When perioperative pain management requires medication, Sean Mackey, MD, PhD, Redlich Professor and chief of the Division of Pain Medicine at Stanford University, noted, “There is a very large number of medications that have been tested in human randomized controlled trials that have shown some efficacy in some aspect of pain.”

To select one that best fits a perioperative patient’s needs, he says, “Start with the goals in mind,” noting these may extend beyond pain relief per se to include quality of life, functional status, and a return to work—all of which may inform which pain relief methods a surgical team may choose early in the perioperative period.

One Size Does Not Fit All

Starting with an individual patient’s goals in mind is one facet of what nearly everyone interviewed for this article said in almost identical words: “One size does not fit all.”

Indeed, most enumerated that the personal nature of pain medicine extended beyond the articulated goals of a patient to the intensity of their disease or injury, the type of surgery a patient receives, the patient’s specific pain response, their receptivity to and tolerance of specific pain relief options, and any existing level of substance use disorder. Tailoring pain relief to the specific patient often requires careful assessment by pain management teams, including for medical history, previous difficulties with pain control, and any current use of illicit drugs. Although this is time-consuming and not always possible (as in the case of Dr. Rieder, who needed urgent surgical intervention to save his injured foot), these efforts pay off in lowered risk of adverse outcomes.

A Paradigm Shift

Other observations resonated across all interviews for this article. First, not all clinical interactions affecting a patient’s opioid use and cessation happen with surgeons; many members of the healthcare team may be involved. As a result, shifting to better management of opioid use goes beyond the behavior of individual surgeons, requiring the buy-in of an entire department or hospital.

Indeed, Dr. Rieder noted that this perspective was the point of his writing a book about the bioethical aspects of his injury: to prompt systematic change.

Although individual surgeons are not the sole factor in effective perioperative pain management, surgeons are important participants in improving opioid use and cessation for patients nationwide. As Dr. Waldman, a pain specialist, noted about the Hospital for Special Surgery’s improved processes for standardizing, reducing, screening for, and tapering opioid use: “The system worked here because we had a surgeon-in-chief and the president of the hospital who were willing to say to all the surgeons, ‘This is the way it’s going to be.’”

As a result, he said, “The surgical departments are very invested in this. They see the value of it, and I think they want to see it succeed. But it was a real paradigm shift, and it didn’t happen until we had the surgeons on board.”

M. Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.

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  3. Gaitanidis A, Gallastegi AD, Van Erp I, et al. Nationwide, county-level analysis of the patterns, trends, and system-level predictors of opioid prescribing in surgery in the US: Social determinants and access to mental health services matter. J Am Coll Surg. 2024;238(3):280-288.
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