Reader Forum: Opioid-Free Surgery − It’s Real

Responses and reactions to our articles and other issues related to physician leadership.

As we follow the national opioid epidemic — with more than five deaths an hour from opioid overdoses, according to federal data — health care is shifting its focus to limiting an individual’s exposure to these drugs.

For most people, first contact with these highly addictive medications is after surgery. Studies reveal that 60 percent of pills prescribed for pain after surgery go unused, making their way to other family members, kept for continued use by the patient to maintain feelings of euphoria, or finding their way into the community. Limiting the number of pills and refills prescribed is a good start, but should we consider not using opioids, or not discharging surgical patients on them?

With the advent of new anesthetic techniques and a long-acting nerve-blocking medication, this option is now a reality. Let’s look at two common surgeries where we see a spike in opioid dependence in relatively young, healthy patients.

Shoulder surgeries and cesarean sections occur daily across the country. With more than 700,000 shoulder procedures and 1 million C-sections performed yearly, thousands of young adult patients will become opioid users. There are several pre-existing conditions that contribute to continued use, such as whether a patient is a smoker or has been diagnosed with alcohol- or drug-based issues or depression, anxiety or chronic pain conditions before surgery, but that’s beside the point. Individuals with a genetic or behavioral predisposition to abuse opioids should be forewarned and treated accordingly, but why not avoid the opioid exposure issue with these patients altogether?

Until recently, post-operative pain management for shoulder surgery has been limited to either a single injection of local anesthetic to numb the nerves sensing the pain or placing a small tube under the skin that provides a continuous supply of anesthetic. Both techniques have limitations and drawbacks. However, the FDA has recently approved using a long-acting local anesthetic for shoulder surgery patients. We now use this medication by providing a single injection, guided by ultrasound. Results have been excellent. Most patients get pain relief lasting between 48 and 72 hours and can then transition to acetaminophen and ibuprofen without needing an opioid.

As with shoulder surgery patients, we also can apply a long-acting, ultrasound-guided, local anesthetic after a cesarean delivery. Obtaining 48 to 72 hours of pain relief again avoids the need, in most cases, for using opioids at home. New mothers have enough on their plate, and our ability to provide long-lasting relief without opioids is essential.

These are just two examples of how newer anesthetic techniques and medications can play a role in providing individuals with extended pain relief after surgery. We are applying this knowledge to every surgical procedure and observing dramatic decreases in opioid use.

Yes, the era of opioid-free surgery has arrived.

Myles Gart, MD, Norfolk, Nebraska

The author is the director of acute pain management at Faith Regional Health Services.

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LISTEN BEFORE LEAPING

I believe the most important soft skill a physician leader possesses is the ability to quietly listen without immediately speaking and trying to jump in and solve the problem.

Physicians are trained first and foremost to be problem-solvers. Evidence suggests that the typical physician forms a diagnosis and solution to a problem within the first 13 seconds of a visit. Having just been a part of a large, unified electronic health record transformation at my health system, the suggested workflow the vendor promulgated was to do this “prework” from the rooming nurse’s chief complaint information before even entering the room and taking a history from the patient.

I believe the most powerful thing we can do as leaders, whether in our patient care or in our team management, is to simply sit and listen. In the modern complexities we face in health care, a moment of reflective listening helps us to engage our patients, colleagues, teams and families, and to be more present to them in powerful ways.

The solution to an immediate problem often presents itself in this listening and moment of reflection more than in a memorized protocol or paradigm or rapid-resolution approach. There are appropriate times for fast-action responses in health care, but being able to separate those few times from everyday listening and reflection has made a tremendous difference in my own leadership journey.

Douglas A. Spotts, MD, FAAFP, Hagerstown, Maryland

The author is the vice president and chief population health officer for Meritus Health.

Have an opinion about something we’ve published? Something else on your mind about physician leadership? Share your thoughts with us. Letters should be exclusive to the PLJ, and preferably no more than 400 words. Submissions will be edited for length and clarity. Email: lmailto:journal@physicianleaders.org