Do patients really need opioid painkillers after colorectal surgery?

Although the opioid epidemic in the United States is currently overshadowed by the urgency of the COVID-19 pandemic, the danger of highly addictive opioid medications remains an issue.

In 2019, an estimated 10.3 million Americans over the age of 12 misused opioids. Almost 37% of all opioids are prescribed in the surgical setting, and of those addicted to narcotics, many report initial exposure in the postoperative period. Opioid overdoses lead to approximately 100 deaths per day in the United States, a rate that has quadrupled since 1999. Up to half of these deaths involve prescription opioids.

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Dr. Atif Iqbal, chief of the Colorectal Surgery Program at Baylor College of Medicine, has dedicated his efforts toward a comprehensive enhanced recovery after surgery (ERAS) protocol, which includes an opioid-free recovery.

In the following Q&A, Iqbal shares how the program is providing patients with an alternative to opioids after surgery.

Q: What kind of medication do you prescribe to patients following surgery?
A: We have strategically tackled the problem of post-surgical pain from different angles. The key to a good patient experience is discussing the care before it happens and setting expectations preoperatively. Before the surgery, patients take a combination of simple, over-the-counter painkillers, such as Tylenol or Ibuprofen, and a non-narcotic anti-seizure/pain medication such as Gabapentin.

Then, immediately before the surgery, the patient receives a spinal injection, which lasts the duration of the operation and for approximately 48-72 hours afterwards. Patients continue using the previously given oral pain medications after surgery. If patients are still in pain after surgery, we consider giving them medications for muscle spasms, such as Flexeril.

If all else fails, a light narcotic painkiller such as Tramadol is then used. Only in situations when the pain is very persistent, do we prescribe opioids. It is our last choice but most patients do not need it.

Q: Does the elimination of opioids affect recovery time?
A: Yes. Eliminating opioids, which helps the patients follow a more rigorous ambulation routine post-surgery, cuts down on recovery time. It also helps with decreasing nausea and vomiting after surgery, leading to earlier return of bowel function and usual activities. Patients also feel better due to the absence of the drowsiness, irritability or other neurologic effects of narcotics.

As part of our enhanced recovery after surgery protocol, we are now getting patients up and walking quickly after surgery. This stimulates healing processes in the body at this early and crucial stage of recovery.  Since most of our patients also have minimal scarring (most of our surgeries are performed laparoscopically or robotically), the majority of our patients leave the hospital within 1-3 days of surgery.

Q: What is the most important advice you would share with someone who is facing colorectal surgery?
A: My biggest piece of advice would be to stay informed. We have started giving our patients the instructions and materials they need to read ahead of surgery. This includes us providing information we would typically give to patients at discharge in terms of after-surgery care.

On the same note, any patient who needs an ostomy bag is provided the opportunity to meet a certified ostomy nurse in clinic for education well before surgery.

We know some patients may not be interested in reading pamphlets, so we are creating a set of informational videos, which present everything the patient needs to understand in a simple, digestible, and comprehensive manner.

If you are going in for colorectal surgery, I recommend you pay attention to the information given by your licensed, certified, and approved healthcare provider.

Dr. Iqbal is an associate professor, chief of Colorectal Surgery and a member of the Dan L Duncan Comprehensive Cancer Center at Baylor.

-By Debbie Sugarbaker, editor in the Michael E. DeBakey Department of Surgery at Baylor College of Medicine

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