My Story: Hospitals Are Undertreating Pain

By Michael Swift, Guest Columnist

Right now, as I type this, I can barely finish because I just got home from a surgery in my abdominal area. I won't get into the details, but a lot of cutting was done, and I was discharged after an agonizing hospital stay. I was given Tylenol and Naproxen for post-surgical pain.

I am now reclined in bed at home and suffering from post-op pain because a major hospital in a city of a quarter million people is undertreating pain. This is the new norm for most hospitals here in Texas.

My wife and I lived in beautiful central Oregon all our lives. We ended up vacating the house we rented and could find no place to live in the entire state that was affordable to us. For family reasons, we moved to the Texas Panhandle.

My wife, seeking a new pain specialist in Amarillo, was denied and bawled-out two times by doctors. She was told by one verbatim: “We don't push dope here. If you want drugs, go to the north side of town."

I almost walked back in after she told me what this doctor had said to her, to punch him in the mouth. But it would do no good trying to help her from a jail cell. She was visibly upset, in tears, humiliated and so hurt. She is a 67-year-old senior with spinal stenosis and a bone disease that is destroying her vertebral column. Even with stellar remarks by her former providers as a "model patient with legitimate pain,” she was still an object for these millennial brats to verbally spit upon.

When living back in Oregon, my wife and I had a wonderful provider in Bend and our lives were fully active. We failed however to do our homework before moving to Texas. When we arrived, we realized that the Texas Medical Board and certain medical groups and doctors decided they wanted to solve the huge drug abuse problem.

The real problem here has been massive amounts of illicit fentanyl, comprising about 75% of overdose deaths, along with heroin, ecstasy and many other street drugs pushed in by the Sinaloa drug cartel. Nevertheless, the medical board went after the doctors and patients because it was easier than addressing the real problem.

A Broken Healthcare System

To say the least, I am saddened, upset and feeling a huge weight of condemnation from individuals here in the medical field. What a broken and detached healthcare system.

We are both leaving Texas for a nearby state, already set up with a new provider there, who is willing to take a good look at her without judgement. I am not leaving though, until I file a complaint against both pain management providers for their unethical, cruel treatment and libelous slander -- with the use of profanity to my wife's face -- all confirmed by the nurse in the exam room.

I will also file a complaint with the Texas Medical Board for the experience I had as a surgery patient. It will fall on deaf ears, but I won't stop until I get a response. To those of you out there who are also suffering and abandoned, take any and EVERY measure available to control your pain, which is robbing you of your life. You have no other choice.

There is a terrible and frightening experience awaiting those who are destined to go under the knife in hospitals that have overreacted to the "opioid crisis” by implementing a new policy of completely abstaining from administering any narcotic pain medication to post-surgical patients.

I suppose I could have screamed at the top of my lungs to demand pain relief, but who wants that on their record. Or worse, to be blacklisted. Thank God I have an alternate source of pain relief, but I am still astounded.

I am a veteran of nine prior surgeries, all of them done over 20 years ago. When I was in the hospital after those surgeries, I was asked by a nurse what narcotic I wanted to choose for pain relief. After that, I stayed healthy, avoided more surgeries and interpreted the many stories I heard about "Tylenol for post-op pain" as nothing but false tales and fear-mongering.

To all and any of you who posted such statements, I sincerely apologize. You were telling the truth.

Michael Swift lives with degenerative disc disease, arthritis and severe migraines.

Do you have a “My Story” to share? Pain News Network invites other readers to share their experiences about living with pain and treating it.

Send your stories to editor@painnewsnetwork.org

Most Americans Believe Opioids Necessary for Pain After Surgery

By Pat Anson, PNN Editor

Nearly 8 out of 10 U.S. adults believe opioids are sometimes necessary to manage pain after a surgery, according to a new survey that found most people are more worried about treating post-operative pain than they are about becoming addicted to opioids.

The online survey of over 2,000 adults was conducted last month by The Harris Poll on behalf of MediaSource and Orlando Health, a large Florida-based healthcare system. The survey comes at a time when many hospitals around the nation have adopted policies that discourage or eliminate the use of opioids after many common surgeries.

A recent study of nearly half a million surgeries performed at U.S. hospitals found that the number of opioid pills prescribed to patients decreased by 50% since 2017. Instead of opioids, hospitals are giving patients acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), gabapentinoids and other non-opioid medications.  

“It's very important for us to keep in mind that people do have pain and people do need pain control. The solution is not to just pull opioids away from people and leave them to fend for themselves,” said Luke Elms, MD, a general surgeon at Orlando Health’s Dr. P. Phillips Hospital. “That is a real problem after surgery that needs to be addressed in a compassionate manner.”

Dr. Elms has implemented a protocol that uses over-the-counter drugs like acetaminophen, ibuprofen and muscle relaxers. He says they are safer medications than opioids and help surgical patients recover faster without side effects such as nausea, dizziness and constipation.

“When I talk to patients and reassure them that we're going to be replacing opioids with a much more effective and safe method, and really talk to them about the risks of opioids that have become much more evident with the research that's come out recently, most patients are very open to the idea,” Elms said in a press release.

But that is not how most U.S. adults feel, according to the survey findings. When asked a series of questions about post-surgical pain, many said they have a strong preference for opioids:

• 78% Believe opioid pain medication after surgery is sometimes necessary

• 67% Expect to receive opioids to manage pain after surgery

• 65% Are more concerned about pain relief after surgery than opioid addiction

• 60% Prefer strong prescription painkillers over OTC pain relievers like ibuprofen

At the same time, over two-thirds of respondents (68%) said they are open to the idea of using non-opioid pain relievers and would be willing to try them. Adults who are employed, have high incomes and those with college degrees are more likely to prefer sticking to opioids.

Opioid addiction is actually quite rare after surgery.  A large 2016 study found that less than one percent of older adults were still taking opioids a year after major surgery.  Another large study in 2018 found less than 1% of patients prescribed opioids for post-operative pain were later diagnosed with opioid dependence, abuse or had a non-fatal overdose.

A recent Mayo Clinic study found that hospital guidelines are useful in reducing the number of opioid pills prescribed after surgery, but sometimes go too far. While most patients were satisfied with their pain control, about 10 percent were not.  

Poorly controlled post-operative pain is associated with increased morbidity, less function and quality-of-life, delayed recovery time, and higher health-care costs. The intensity of acute pain during or after surgery is also predictive of developing of chronic pain.

Gabapentinoids Ineffective for Pain Relief After Surgery

By Pat Anson, PNN Editor

Would you want to take Lyrica (pregabalin) or Neurontin (gabapentin) for pain relief after a major surgery? Both drugs belong to a class of nerve medication called gabapentinoids that are increasingly being prescribed to patients perioperatively (after surgery) as an alternative to opioid medication.

But gabapentinoids also have risks and there is little evidence to support their use for postoperative pain relief, according to a large new study by a team of Canadian researchers.  

“No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients,” wrote lead author Michael Verret, MD, a resident at Laval University in Quebec City.  

Verret and his colleagues conducted a meta-analysis of 281 clinical trials involving nearly 25,000 patients undergoing a wide range of surgeries, including orthopedic, spinal and abdominal operations.

Their findings, recently published in the journal Anesthesiology, indicate that the analgesic benefits of pregabalin and gabapentin after surgery are negligible, regardless of the dose or type of operation. Gabapentinoids were also ineffective in preventing chronic pain from developing after surgery, one of the primary justifications for using the drugs postoperatively.

“Gabapentinoids were also associated with a greater incidence of adverse events, namely dizziness and visual disturbance, while other major adverse events such as respiratory depression and addiction are not reported or are underreported,” said Verret.

The findings contradict guidelines published by the American Pain Society (APS) in 2016,  which advocate “around the clock” use of gabapentin, pregabalin and other nonopioid drugs both before and after surgery.

“The panel recommends use of gabapentin or pregabalin as part of a multimodal regimen in patients who undergo surgery. Both medications are associated with reduced opioid requirements after major or minor surgical procedures, and some studies reported lower postoperative pain scores,” the APS guideline states.

“The panel suggests that clinicians consider a preoperative dose of gabapentin or pregabalin, particularly in patients who undergo major surgery or other surgeries associated with substantial pain, or as part of multimodal therapy for highly opioid-tolerant patients.”

‘Evidence of Harm’

Although opioid addiction is relatively rare after surgery, dozens of U.S. hospitals followed the lead of the APS and other medical guidelines by stopping the use of opioids for certain surgeries.

Cleveland Clinic Akron General Hospital, for example, adopted a policy of only using gabapentin and other non-opioid analgesics for colorectal operations.

“It is now clear that over the past two decades, evidence of benefit from routine perioperative administration of gabapentinoids has diminished, while evidence of harm has increased.”

— Dr. Evan Kharasch

Critics say gabapentinoids have become a trendy alternative for post-surgical pain relief, even though evidence supporting their use is minimal.

“It is now clear that over the past two decades, evidence of benefit from routine perioperative administration of gabapentinoids has diminished, while evidence of harm has increased. If any potential benefits exist in ‘special populations,’ published reports have yet to identify the benefits or the populations,” lead author Evan Kharasch, MD, Editor-in-Chief of Anesthesiology, wrote in an editorial.

“The good intentions that led to routine gabapentinoid use should be redirected to lead the way out. The French Society of Anesthesia and Intensive Care Medicine now states that gabapentinoids should not be used systematically or in outpatient surgery. Other societies should follow. As the weight of evidence has shifted and the risk–benefit balance tilted away from benefit, evidence-based practice impels revising if not eliminating the routine use of perioperative gabapentinoids in adults.”

It's too late for the APS to change its guideline. The organization filed for bankruptcy in 2019, ironically because of the high cost of legal fees in defending itself against opioid litigation.

While the CDC’s controversial opioid guideline does not advocate using gabapentinoids for post-surgical pain, it does recommend their use in treating chronic pain -- with little to no mention of their side effects.

One of the co-authors of the CDC guideline, Dr. Roger Chou, also played a significant role in drafting the APS guideline. Chou is currently heading much of the research being conducted by the CDC as it prepares to update and possibly expand its 2016 guideline.

Surgery Patients in Vermont Getting Fewer Opioids or None at All

By Pat Anson, PNN Editor

The 2016 CDC opioid guideline was never intended to reduce the use of opioids for post-surgical pain. In fact, studies show that long-term use of prescription opioids after surgery is rare. Nevertheless, a number of states and hospitals have policies designed to reduce the use of opioids after surgery -- many of them modeled after the CDC guideline.  

Vermont was one of the first, adopting a rule in July 2017 that encourages doctors to use non-opioid pain relievers as first-line treatments for post-operative plan. If they do prescribe opioids, patients are initially limited to no more than 10 pills. The regulations also require doctors to discuss with patients the risk of opioid addiction and overdose.

This state-mandated policy has led to significant reductions in opioid prescribing to surgery patients at the University of Vermont Medical Center (UVMMC) without impacting patient satisfaction in pain management, according to a new study presented at the American College of Surgeons Clinical Congress.

The study evaluated opioid prescribing at UVMMC for 15 common operations for 12 months before the regulations went into effect and for 17 months afterward.

During that period, the daily morphine milligram equivalent (MME) dose declined by 33 percent, from 96 MME to 64 MME afterwards. The proportion of patients who did not receive any opioids after surgery more than doubled, from 12.7 to 26 percent. That’s one of every four patients.

Prescription refill rates for opioids increased from 5.5 percent to 6.3 percent, and the percentage of patients reporting an inadequate amount of pain medication also rose, from 11 percent to 12.3 percent. But those increases were not considered statistically significant by the researchers.

“The clear trend is that physicians are prescribing less, patients are using less, and there is no appreciable change in patient-reported pain control or satisfaction after implementation of these regulations,” said study presenter Mayo Fujii, MD, a clinical instructor in surgery at the University of  Vermont Larner College of Medicine.  

“That patients are using less may reflect the impact of patient education efforts to establish expectations of postoperative pain and use non-opioid pain management strategies, as well as public awareness of the opioid epidemic.”

Patient education about non-opioid analgesia increased from 82 percent to 98 percent during the study period, as did education on safe opioid disposal (19 percent to 52 percent).

“Patient education, particularly encouraging non-opioid pain management strategies was something that clearly increased after these regulations went into effect,” Fujii said. “It’s an intervention that’s easily implemented and may contribute to patients using less opioid medication than they otherwise would have.”

Vermont Overdoses Still Rising

The Vermont regulations appear to have been successful in reducing the frequency and amount of opioids prescribed to both acute and chronic pain patients. But what about their impact on addiction and overdose rates?  The evidence there is mixed at best.

According to state health officials, fatal overdoses in Vermont rose from 96 deaths in 2016 to 110 deaths last year. Most of those overdoses involve illicit fentanyl or heroin, not prescription opioids. Only 28% of the deaths in 2018 were linked to opioid painkillers, but it’s not known if the pills were prescribed or obtained illicitly.

A recent study in neighboring Massachusetts found that only 1.3% of overdose victims who died from opioid medication had an active opioid prescription – suggesting that the vast majority of pills were stolen, diverted or bought on the street.

As in other states, many doctors in Vermont have grown cautious about their opioid prescribing and some are aggressively tapering patients off opioids. A recent study of tapering in Vermont found only 5 percent of patients had a tapering period longer than 90 days. The vast majority (86%) were rapidly tapered in three weeks or less, including about half who were cut off without any tapering. Many of those patients were hospitalized for severe withdrawal symptoms, including respiratory failure.

A new federal tapering guideline suggests tapers of 5% to 20% every four weeks, although slower tapers of 10% a month may be appropriate for patients taking opioids for more than a year.

Genetics Play Significant Role in Post-Surgical Pain

By Pat Anson, Editor

An important new study has confirmed that a patient’s genes really do play a role in determining whether they develop chronic pain after surgery.

Researchers in China collected blood samples from 1,152 surgical patients to look for genetic variations in 54 "pain-related" genes which have been associated with pain sensation. Patients were then contacted a year later to see if they had chronic post-surgical pain.

A surprising number – one out of five patients – still experienced pain at the wound site, and 33 percent of them said their pain was severe.  Patients with pain also reported problems with their overall health, as well as daily activities such as mood, walking, relations with others, sleep, and quality of life.

Aside from genetic factors, the study also found patients younger than 65, males, and those with a prior history of chronic pain were at increased risk. The study is published online in the journal Anesthesiology.

"Our study not only shows there are common genetic variations among people that may help to identify whether they are at high-risk for developing chronic pain after surgery, but it also helps explain why only a fraction of patients ever even experience persistent pain," said lead researcher Matthew T.V. Chan, MD, at the Chinese University of Hong Kong.

"Until now, the genetic variations associated with chronic post-surgical pain have not been well identified."

One genetic variation in particular - a gene found in the nervous-system called brain-derived neurotrophic factor (BDNF) - was found to be most frequently associated with chronic post-surgical pain. Researchers confirmed the finding in a study on laboratory mice.

The researchers also found that genetic variations account for a higher percentage of chronic post-surgical pain (between 7 percent and 12 percent) than other risk factors such as age, sex, smoking history or anesthesia technique (between 3 percent and 6 percent).

Chronic post-surgical pain is one of the most common and serious complications after surgery. Previous studies have found that chronic pain was common after abdominal hysterectomies (25.1%) and heart or lung surgery (37.6%).

“Considering that more than 230 million surgeries are performed each year worldwide, the data would imply that millions of patients will continue to suffer wound pain, months to years after their surgery,” researchers said.

The study comes at a time when many U.S. states have adopted or are enacting laws that would limit the supply of opioid medication to just a few days for acute short-term pain. Minnesota, for example, is close to adopting strict guidelines that would limit the dose and supply of opioids to three days for acute pain and seven days after a major surgery.