Other Ways to Manage Pain After Surgery
February 17, 2022 — Nick Dawson, a 42-year-old ski instructor from Montana, knows a thing or two about anterior cruciate ligament repair. He tore his anterior cruciate ligament four times and had surgery for the injury three times.
A common but painful operation, doctors often prescribe a hefty course of opioids to relieve pain after the procedure. And that was the course that Dawson’s surgeons followed. But with each repair, Dawson used fewer and fewer pills until he finally gave them up for the third time.
“The first time, I had no real idea of what to expect from my recovery, so I took opioids as prescribed to get ahead of the pain,” he says. “I’ve experienced mood swings and found that medications don’t actually relieve pain – instead, they make you ignore the pain.”
What worked best for Dawson was a combination of a high dose of anti-inflammatory drugs and an ice pump that the doctor sent home with him. After the second operation, he began to take fewer opioids but more anti-inflammatory drugs in combination with an ice pump.
“After a couple of days of this approach, I stopped taking opioids,” he says.
Finally, after the third operation in 2012, Dawson stopped taking opioids altogether, despite being prescribed by a doctor.
“I figured out what I didn’t like and also what worked best,” he says. “I was really wondering why the anti-inflammatory approach wasn’t something that doctors used from the start instead of opioids.”
It looks like Dawson was one step ahead in his self-proclaimed approach. A new study from the Mayo Clinic aims to find out if patients recovering from anterior cruciate ligament and rotator cuff surgery can better manage pain with non-opioid drug combinations. The results are promising, and it’s a good move.
About 3 out of 10 opioid prescriptions are related to orthopedic and spinal conditions, according to Mayo lead researcher Kelechi Okoroha, MD. The standard prescription is 30 to 60 tablets for up to 2 weeks. Stopping the use of opioids after these surgeries can help reduce high rates of opioid addiction and sometimes subsequent death.
“Some patients will simply be more prone to addiction, even after a brief introduction,” Okoroha says.
In 2019, the US Department of Health and Human Services estimated that 70,630 people died from opioid overdoses and 10.1 million people abused drugs.
“Here in the United States, opioids are pretty standard after surgery,” Okoroha says. “We have an opinion that there should be no pain after the operation.”
This approach and beliefs date back to the mid-1990s when OxyContin entered the market as a “softer” class of opioids marketed as less addictive. Insurance companies and doctors agreed, and by 2017, a public health crisis with opioid addiction had erupted in the US. Now doctors are looking for ways to break the cycle.
Even before this round of orthopedic research, as a surgeon, Okoroha began looking for ways to stop using opioids in joint replacement surgeries. Finding success there — patients found the protocol to be as effective or more effective than opioids — Okoroha decided to move on to other areas of orthopedic procedures to see if he could achieve the same results.
Dividing their study into two studies, Mayo’s team first examined an alternative treatment protocol with 62 patients with anterior cruciate ligament repair, dividing them into two groups: one used the standard opioid plan of hydrocodone and acetaminophen. In the second group, researchers used nerve blockers, acetaminophen, muscle relaxants, and non-steroidal anti-inflammatory drugs (NSAIDs).
“This provided multiple agents targeting multiple sources of pain,” explains Okoroha.
Patients were asked to rate pain on a visual analog scale (VAS), which ranged from “no pain” to “worst pain.” All patients in the non-opioid group reported satisfactory pain relief and minimal side effects. This was applied even a week after the operation.
That second group was compiled from 40 patients undergoing surgery for rotator cuff surgery. Of these, 23 were in the traditional opioid group, and 17 were in the no-opioid group. On the 1st and 4th days after surgery, the traditional group had significantly higher levels of pain according to the VAS scale. The non-opioid group scored significantly lower on each measured score.
All patients in both studies underwent nerve blocks before surgery. Dawson says doctors used this approach during his third anterior cruciate ligament surgery.
“I felt it helped a lot with the pain in the first 24 hours,” he says.
Recovery remained unchanged after surgery for both the anterior cruciate ligament and rotator cuff groups. Okorokha was pleased with the results.
“The main takeaway is that we don’t need to resort to opioids after routine sports operations,” he says. “We believe that if we can apply this to these orthopedic procedures, we can apply this to others.”
In both studies, patients reported side effects ranging from drowsiness and dizziness to gastrointestinal symptoms. But in the rotator cuff study, patients who received the experimental protocol fared slightly better.
Okoroha says more research will follow on new pain management plans in other orthopedic surgeries.
Meanwhile, “healthcare professionals should see if their patients can do without opioids,” he says. “If we can combine evidence with adoption, we can eventually change standard practice.