Opioid Addiction and Surgery: Pain Management for Recovering Addicts
- While opioids present numerous benefits in postsurgical pain control, they are also at the center of an ongoing national crisis.
- Many recovering addicts fear that surgery and the ensuing exposure to opioids may trigger relapses.
- Researchers are exploring non-opioid options for anesthesia and pain management in high-risk patients.
Max Baker, a former opioid and heroin addict, was clean for over a year when a serious car accident landed him in the hospital.
Concerned that anesthesia and postsurgical pain killers would cause him to have a relapse, Baker told his surgeon, Dr. James Shenko, about his history with addiction.
“It became a big discussion between myself and anesthesia,” Shenko says. “They were uncomfortable treating [him] differently than other patients because they felt that wasn’t fair to the patient.”
In the end Baker received opioids as part of his surgical anesthesia, and a small dose of Vicodin to help with postsurgical pain.
Baker relapsed, and died of a heroin overdose less than a month later.
Opioid addiction is now referred to as an epidemic in the United States. According to the Center for Disease Control and Prevention (CDC), an average of 91 Americans die each day from opioid overdoses. What’s more, a Morbidity and Mortality Weekly Report (MMWR) from 2016 reported that these drug overdose deaths nearly tripled from 1999-2015.
Although opioids do provide very real benefits, doctors are now struggling with the question of what to give addicts or recovering addicts in need of anesthesia and post-surgical pain management.
Alcoholism and Pain Management
Current and former opioid addicts aren’t the only patients that need concern themselves with alternative pain management options. The use of opioids by someone who is prone to heavy drinking presents its own unique set of challenges.
Alcohol and opioids have well documented cross-tolerance effects. In other words, an increased tolerance to alcohol could mean an increased tolerance to opioids, even in patients who don’t regularly use or abuse them.
What’s more, alcohol and opioids are both central nervous system (CNS) depressants. In fact, opioids enhance the effects of alcohol and can lead to serious complications such as respiratory depression.
Finally, alcoholism is its own form of drug addiction, and alcoholics (or those with a history of alcohol abuse) are more susceptible to developing other drug dependencies.
The Basic Principles of Pain Management
No surgeon or anesthesiologist wants their patient to suffer. For this reason, many medical professionals and organizations offer guidelines regarding effective pain management. These common principles can be summarized as follows:
- Pain relief is key.
This is especially important for anesthesiologists, given that inadequate pain control during surgery can lead to shock. Acute pain during and after surgery should be treated like a medical emergency.
- Pain should be measured regularly.
Pain levels rise and fall, and it can take time to determine the appropriate post-surgical dosage. Your surgeon should be regularly screening your experience by talking to you about any discomfort and/or side effects you are encountering.
- Pain is subjective.
Surgeons should not compare one patient’s postoperative experience with another’s. Pain management strategies that work for one patient may not work for another. What’s more, when asked to rate pain in a scale of 1-10, one patient’s “6” could easily be another patient’s “8.”
- Pain should be tackled from multiple angles.
There is more to pain management than just drugs. Depending on the procedure in question, surgeons should be turning to other strategies, like heat/cooling, compression, physical therapy, and other methods to complement pain pills.
- Patients and caregivers should be educated about pain management.
Everyone involved should understand what an acceptable level of discomfort is and how to responsibly handle serious pain medications.
Depending on the extent of the surgery, alternative medications can be used by surgeons and anesthesiologists in cases where the patient has a history of opioid addiction or alcoholism.
Local anesthesia does not contain opioids. However, some research suggests that opioid tolerance can create the need for higher dosages of some local anesthetics and even delay the onset of the anesthetic.
On the other hand, general anesthesia almost always involves opioids, and many anesthesiologists don’t feel comfortable offering anything less. Whether your procedure requires this or local anesthesia will depend on the procedure itself and your surgeon’s best practices.
Researchers are becoming increasingly aware of the problem of opioids for current and former addicts.
A recent study at Select Physicians Surgery Center in Tampa, Florida looked at the effectiveness of general anesthesia without morphine or other opioids. Instead of the usual medications, patients received varying combinations of ketorolac, lidocaine, magnesium, and sub-anesthetic ketamine. The study followed 1,009 patients through surgery and pain treatment — both the patients and surgeons involved reported success.
This new strategy for pain management holds promise for more than just struggling and recovered addicts. Dr. David Samuels, who lead the study, noted that fentanyl, the most commonly used opioid in general anesthesia, caused increased pain sensitivity after the fact, a phenomena known as opioid-induced hyperalgesia. However, 64% patients who received the non-opioid general anesthetic did not require any pain relievers in the post-anesthesia care unit (PACU).
What’s more, only 11% of these patients experienced postoperative nausea, as opposed to the usual 50-80% of patients who receive traditional general anesthesia.
Note that these efforts are still in their budding stages. There’s no guarantee that your prospective surgeon and anesthesiologist will be on board with opiate-free general anesthesia.
Post-Surgical Pain Management Alternatives
Once you’re out of surgery, the story isn’t necessarily over. Depending on the extent of your surgery, you could still be in store for some significant pain, and as such it’s essential to work with your surgeon in order to mitigate any potential discomfort.
Less severe pain can be treated with prescription doses of non-addictive pain medicine. Nonsteroidal anti-inflammatory drugs like ibuprofen are popular post-procedure choices but may increase the risk of bleeding. Acetaminophen may also be a good choice if its blood thinning properties aren’t a concern.
Note that while you can purchase these painkillers over-the-counter, you shouldn’t seek to manage your own pain and dosages. Appeal to your doctor for a prescription with the appropriate dose and only take the painkillers prescribed to you.
If your pain is more severe, you may be looking at a prescription for a less addictive medication like Tramadol, which is an opiate agonist and not technically classified by the federal government as a narcotic. Tramadol is an antidepressant with a minor effect on opioid receptors. It’s commonly considered a good choice for patients for whom addiction is a concern. Some doctors may also try low dosages of stronger narcotics, like hydrocodone or oxycodone, but this has shown mixed results.
Also ask your prospective surgeon about non-opioid anesthetics like bupivacaine. This drug, marketed under the brand names Marcaine, Sensorcaine, and others, is similar to lidocaine. Its effects generally last approximately 12 hours, but can be prolonged by combining it with another drug called Exparel.
Exparel’s unique composition creates a slow release of the anesthetic that lasts up to three days. In this way, the anesthetic can become an effective post-surgical pain management solution for recovering addicts. In fact, the drug is so effective that many patients are opting to use it, regardless of their history with opioids.
Despite these options, opioids remain difficult to avoid, especially when major surgery is involved. Thankfully, there are other resources at your disposal that can help you through a difficult postoperative transition.
» If you would like to discuss your options and learn more about plastic surgery pain management, ask a doctor on our forum.
Resources for Recovered Addicts
Dr. Stuart Gitlow, former president of the American Society of Addiction Medicine (ASAM), suggests that surgeons seek the counsel of addiction specialists when working with recovering addicts. Having an addiction specialist on hand can help identify opioid misuse early on and allow actions to be taken before the problem grows. However, demand for these specialists is very high these days, so there’s no guarantee one will be available to you.
In the meantime, talk to your surgeon about making a postoperative health care plan. Agree to the conditions of this plan prior to surgery to help you stay accountable should you find yourself at risk of developing or worsening a dependency to opiates.
- Minimum effective dose: Agree to keep dosages down even where minor discomfort is involved.
- Periodic weaning: In order to best assess the minimum effective dose, work with your surgeon to scale back the dose on a semi-regular basis and reassess the pain.
- Drug screening: Agree in advance to a regular schedule of drug screening tests after surgery. This will help to keep you accountable and make it easier for your surgeon to get you the aid you need should they see signs of opioid abuse developing.
- One opioid-prescribing physician: In case pain complaints transform from genuine need to drug-seeking behavior, it’s helpful if all your medication comes from one source. In this way your surgeon or attending physician can better monitor any signs you may be relapsing.
- Recovery drugs: There is some evidence to suggest that recovering addicts who are still taking a recovery drug like methadone or buprenorphine are actually less susceptible to relapse due to pain medications. It’s possible that going back on opiates and later resuming addiction treatment for a time will help patients through the postoperative period, including easing the effects of opioid withdrawal symptoms when combating physical dependence.
In addition to the measures outlined above, reach out to close friends and family, as well as your primary physician. Tell them that you’re planning surgery and what your concerns are. The bigger your support network, the easier recovery will be.
Specific Considerations for Cosmetic Surgery
It’s worth noting that cosmetic surgery is elective. Recovering addicts like Max Baker aren’t given a choice as to whether or not to undergo surgery and expose themselves to opioids.
However, if you’re a former addict looking into an elective cosmetic surgery, you have the time and opportunity to do your research and make sure you have every resource at your disposal.
» If you are a recovering opioid addict who is interested in cosmetic surgery, use our doctor directory to find a board-certified plastic surgeon near you and discuss your post-surgery pain management options. Ideally you will locate a nearby healthcare professional who has experience working with high-risk patients for opioid dependency.
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