Opioid Safety After Surgery

“I’m going to have surgery soon and I have been told I will be given an opioid medication to control the pain after the operation. But I see stories of people getting hooked on opioids all over the news, and I’m scared to take them. Am I right to be worried?”

Paul Taylor, patient navigation advisor at Sunnybrook Health Sciences Centre in Toronto, recently fielded this question in a special to the Globe and Mail. The answer recommended that concerns about opioids be “kept in perspective” and that they can be extremely useful in managing short-term pain, noting that “problems can arise when patients end up on the drugs for longer than is necessary.” The addictive properties of opioids are indeed reason for concern.

We wanted to add an additional perspective, particularly on safe use of opioids for acute pain after surgery, especially while patients are still in the hospital receiving care.

Opioids are depressants that affect respiratory function. When somebody overdoses on opioids, their breathing slows down significantly. Oxygen and carbon dioxide levels become dangerously impaired, leading to the possibility of losing consciousness, slipping into a coma, or stopping breathing completely. During surgery, patients are hooked up to monitors that continuously track oxygen and carbon dioxide levels. These monitors can provide early indication of opioid-induced respiratory depression.

After surgery, however, patients in the hospital usually continue to receive opioids to manage pain, often without these continuous monitoring devices hooked up. Instead, it is common for nurses to conduct “spot checks”. In other words, your nurse will check on you every two to four hours to make sure you are still conscious and breathing. Several patient safety organizations have called for continuous electronic monitoring of all patients receiving opioids – which provides the earliest indication of opioid-induced respiratory depression – because, by the time a spot check reveals you have overdosed, it may be too late to do anything about it.

In sharing these details, we do not intend to be alarmist. Opioid use is generally safe for most patients, and most patients are safe during recovery, even when they are prescribed opioids. However, patients should be aware of the risks associated with opioid use for acute pain after surgery so that they know what to expect.

There are many questions you can ask to help mitigate risks related to opioid use for acute pain:

1. Ask your doctor about a pain management plan involving more than just opioids.

In a webinar on opioid safety, one pain management educator and clinical consultant described the problem this way:

“When someone has some mild pain, we give them opioids. They have a little more pain, we give them more opioids. They have severe pain, we give more opioids. And, of course, at the top of this pyramid is where we see adverse events including patient deaths.”

Other drugs or therapies exist that reduce pain after surgery. In addition to opioids, ask your doctor to consider non-opioid–and even non-drug–options. Managing pain with more than one treatment is called a multi-modal pain plan.

The American Pain Society (APS) published a clinical practice guideline advocating for multi-modal pain management plans. According to the APS:

“Randomized trials have shown that multimodal anesthesia involving simultaneous use of combinations of several medications — acting on different pain receptors or administered through different techniques — are associated with superior pain relief and decreased opioid consumption compared with use of a single medication administered by one technique.”

In other words, research shows that using several tools in the toolbox does a better job of reducing pain; plus, patients consume less opioids, minimizing their risk for overdose, respiratory compromise, addiction, and dependence.

One last point: expect to manage your pain rather than eliminate it completely and work with your doctor to come up with a pain plan that works for you. Over time, people can develop tolerance for opioids, meaning that you need to consume more opioids for the same degree of pain relief. By managing expectations about your pain levels after surgery, you will be mindful about the opioids you consume and can reduce your likelihood for adverse outcomes.

2. Ask your post-op team to work through the PCA Safety Checklist.

Patient-Controlled Analgesia (PCA) is a common way for managing pain after surgery. Patients are hooked up to an infusion pump (called a PCA pump) and they can self-administer a dose of pain medication prescribed by their physician by pushing a button. The PCA pump has threshold limits to prevent administering too much medicine too quickly–in theory. But, since every patient is different, these pumps can be dangerous when not hooked up to oxygen and carbon dioxide monitors.

The PCA Safety Checklist is a free tool developed in collaboration with patient safety experts that helps clinicians keep patients safe when they receive opioids via a PCA pump.

The checklist enables clinicians to assess the risk for over-sedation and respiratory depression, educate patients about using a PCA pump, and make sure that patients are continuously monitored with the oxygen and carbon dioxide monitors we mentioned (called pulse oximetry and capnography, respectively), both of which may provide early indication of respiratory depression.

By asking your doctor to use the PCA Safety Checklist, you are asking them to consider recommendations developed by a leading panel of advisors before making the decision to prescribe you opioids via PCA, thereby helping to mitigate risks associated with opioid use after surgery.

3. Ask about the worst-case scenarios.

What happens if something goes wrong? What happens if you slip into respiratory depression? What happens if you become addicted or dependent?

Hospitals should have a rapid response team (RRT) who brings critical care expertise to the bedside when something goes wrong. If you are prescribed opioids after surgery, insist that the RRT includes a credentialed respiratory therapist. Respiratory therapists receive specialized training in making sure patients breathe; it almost goes without saying that their expertise is crucial if something goes wrong and you experience respiratory depression. The response plan should also include the potential administration of naloxone, an agent that reverses the effects of opioids, saving lives. For additional resources, refer your doctors to these clinical toolkits by the Institute for Healthcare Improvement and ask them how their RRT operates and responds to emergencies.

In the event of addiction or dependence, you may be referred to other specialists. Ask each doctor you meet about their experience with weaning patients off opioids. Many doctors receive training about how to prescribe opioids, but it can be a major challenge to find a doctor trained in helping you wean off of them. This first-hand account in the Washington Post by a patient who became dependent on opioids paints a picture of how difficult it can be to become independent of opioids once you are hooked. It is important to make sure that at least one of your doctors knows how to wean you off the drug if necessary.

On a concluding note, it bears repeating that opioid use is safe for most patients. But they are also linked to respiratory depression, “a serious patient safety risk that continues to be associated with significant morbidity and mortality” according to the Anesthesia Patient Safety Foundation.

Be aware of the risks and ask the right questions. Help the doctors keep you safe by actively participating in your own safety plan.

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