In addition to the ravages of COVID-19, drug overdoses are causing people to die prematurely.
Misuse of opioids is to blame for most overdoses and some people become addicted after surgeries.
That’s why hospital experts are working hard behind the scenes — and well before patients arrive for necessary surgeries — to dramatically drive down opioid use during and after surgeries.
Preventing opioid addiction is a cause close to Lisa Casanova-Sidoti’s heart. That’s because the nurse and clinical quality specialist at UCHealth University of Colorado Hospital has lost two family members who suffered from addiction.
Her brother had been in recovery, then died of a drug overdose. Her sister was the victim of a recent homicide after fighting drug addiction for years years and living in dangerous circumstances on the streets of Los Angeles.
Casanova-Sidoti’s sister had been a talented gymnast and ballerina as a girl. She trained with renowned Russian ballet teachers and was on track to compete in the 1984 Olympics.
“She was very good at everything she did,” said Casanova-Sidoti.
Then when Casanova-Sidoti’s sister was about 14, she started taking drugs to deal with the pressures she was facing.
“She started dabbling. First, it was prescription drugs, then she quickly moved to heroin. The next wave was fentanyl. We can follow the waves of drug abuse and see my sister’s story,” Casanova-Sidoti said of her sister who was four years older. “It just escalated, escalated and escalated.”
Casanova-Sidoti has been a nurse for 35 years and has a Doctorate in Nursing Practice. Watching her sister struggle changed her focus from being a surgeon to leading her to a career in nursing.
While Casanova-Sidoti understands that some people need opioids, she and many other medical experts are working to reduce unnecessary use of the drugs. Casanova-Sidoti encourages colleagues to think before prescribing addictive medications.
How hospitals are reducing opioid use during surgery and recovery
Many years ago, few medical experts thought much about pain management. Then, in the late 1990s, a group of international experts started a movement called ERAS, which stands for Enhanced Recovery from Surgery. Now a nonprofit, the ERAS Initiative advocates for changes in medical protocols to help patients recover much more quickly from surgeries. One strategy is to reduce the use of opioids during surgery and when patients are recovering.
Sadly, as the ERAS movement was gaining steam, so, too, were intentional efforts by opioid manufacturers to push pain killers on naïve patients and doctors.
The Sackler family, which made billions in profits from opioids, is now settling hundreds of lawsuits along with Purdue Pharma for their role in the opioid epidemic.
“Pharmaceutical reps really pushed drugs like Oxycontin. They said the efficacy was there and the addictiveness would not increase. We now know that’s not true,” Casanova-Sidoti said.
As lawyers and state attorneys general try to extract billions of dollars from opioid makers, hospital leaders are sharply cutting opioid use.
The efforts to reduce opioid use in hospitals are absolutely critical because some studies show that as many as 10% of people who received opioids during or after a minor or major surgery can become addicted. Millions of people every year go to hospitals or outpatient surgery centers for procedures, so the pool of vulnerable people is quite large. (Read more about rates and risk factors of prolonged opioid use after surgery.)
“Pain management used to be an afterthought, but now it’s a central focus of planning,” Casanova-Sidoti said. “This is an evidence-based protocol. We standardize care to minimize the stress response and to reduce post-operative pain, complications and length of stay in the hospital. We’re improving outcomes while expediting recovery.”
Opioid use has been declining over the years, thanks to attentive hospital leaders who have pushed for much greater awareness and less reliance on addictive medications.
Colorectal surgery departments around the world became the first to adopt ERAS standards and dramatically change protocols years ago. Colorectal surgeons were also the first to lead the way with ERAS protocols at University of Colorado Hospital. They started just before the pandemic in December of 2019. And now providers doing joint replacement surgeries also have followed suit along with other surgical programs throughout the UCHealth system.
Some over-the-counter medications can help hospital providers to cut opioid use and prevent infection
The key to cutting opioids is to use multiple non-opioid pain medications in combination with one another. Together, they work just as well or better than opioids and pose far less risk for long-term addiction.
The non-opioid pain medications include the following:
- Lidocaine, a local anesthetic.
- Non-steroidal anti-inflammatory drugs (NSAIDs), common pain-reduction medications. The most common NSAID is ibuprofen. Another is meloxicam, a drug used to treat arthritis. And doctors also use ketorolac, a stronger NSAID that requires a prescription.
- Pain-reducing medications like acetaminophen.
- In some cases, A2 agonists, which are blood pressure medications that, surprisingly, also can block pain.
- This is an anti-nausea patch often used to prevent sea sickness. It can also fight nausea related to medical procedures or medications.
“Surprisingly, in combination, these medications have a synergistic effect and work together to help decrease pain,” Casanova-Sidoti said.
How common non-opioid pain medications reduce pain
Reducing pain starts before surgery.
“In pre-op, we start with acetaminophen and meloxicam. We also place a scopolamine patch to reduce nausea,” Casanova-Sidoti said.
Patients who are having a less invasive, laparoscopic surgery will receive medications through an I.V. For those having an open surgery with a large incision, the team can use a variety of pain management tools. For example, they can give medications via an epidural or what’s known as a transverse abdominis plane block to create a localized block against pain.
“When anesthesiologists perform epidurals, they typically use an opioid sparing technique. Sometimes opioids are indicated and needed, but we’re actively trying to decrease the amount used or use none at all.”
Once the pre-operative medications are set and the surgeons are ready to begin, the anesthesia provider will start an infusion of lidocaine. Patients receive lidocaine during the surgery and for up to two to three days after surgery. It’s also common to administer one dose of ketorolac (the generic version of a Toradol) at the end of surgery to blunt pain as the patient regains consciousness, Casanova-Sidoti said. In addition to preventing addiction, decreasing or avoiding opioids can also help reduce hospital stays and can decrease negative side effects like constipation.
But it’s much more complicated to use the combination of non-opioid medications.
“It takes a lot of planning. We have to be strategic about the timing. We really want to drive down the pain,” Casanova-Sidoti said.
After surgery, patients receive scheduled doses of acetaminophen. When necessary, nurses also can give doses of ketorolac (the stronger version of ibuprofen) and routine doses of pregabalin (Lyrica). Together, these common medications can be just as effective, if not more so, than opioids.
Making opioids the exception, not the default choice for pain reduction
If patients are suffering severe breakthrough pain, doctors can order opioids. But under the new protocols, opioids are now the exception, not the default choice.
“Every now and then, we have a patient who needs a pump that can push opioids. But, we make every effort to focus on these multi-modal pain medications to decrease the amount of opioids needed,” Casanova-Sidoti said.
More and more patients who have coped with addiction themselves or have family members who have struggled come in for surgeries asking to avoid opioids.
“We’ve made such an impact on that person’s life. Now we want to impact everybody,” Casanova-Sidoti said. “We want to create an experience that’s positive, where everyone has optimal results and can get back to a great quality of life. That’s what this is all about,” she said.
With each individual who is spared from opioids, Casanova-Sidoti thinks of her sister and brother. She wants to spare other families the tragedies her family has experienced.
“Helping people is the biggest thing I can do. It’s my way of having an impact,” she said.
“We improve the lives of patients, not just during their experience in the hospital, but afterwards too. They recover much faster without opioids.”