There is a statistic Kristin Rojas, M.D., a gynecologist and breast cancer surgeon at Sylvester Comprehensive Cancer Center, part of the University of Miami Health System, cannot get out of her mind.
“In 2018, more than 60,000 people died from a drug overdose, and two out of three of those were related to opioids," she says. "This is more than the number who die from breast cancer each year. I remember that number because that’s the population of my hometown of Victoria, Texas.”
Dr. Rojas is well aware of the role that surgeons play in this national crisis. “Surgeons prescribe 70% of opioid medications, and the risk of persistent use following breast cancer surgery is significant. Up to 10% of patients continue to fill opioid prescriptions one year after surgery.”
Many addictions also begin when another family member takes the prescribed medication the patient left in the medicine cabinet.
Better outcomes – without opioids
Determined to help turn the tide on America’s opioid epidemic, Dr. Rojas worked with her team to design and implement a pilot study utilizing enhanced recovery protocols to eliminate the need for opioid prescriptions in patients undergoing breast surgery. The study compared pain scores in two groups of patients, one day and one week after surgery. A control group received traditional opioid-based perioperative pain management; the other received a combination of medications called multimodal analgesia, or different types of non-opioid alternatives before, during, and after surgery to prevent and treat pain. What Dr. Rojas and her colleagues discovered is good news for patients undergoing breast cancer surgery. Patients in the group receiving opioid-sparing multimodal analgesia reported lower pain scores than those in the control group.
Aside from their addictive nature and side effects, such as nausea and constipation, there are other reasons to avoid opioids. Research indicates that they alter the body’s immune response and also affect the brain’s ability to regulate the perception of pain, which prolongs recovery time. One study demonstrated that opioids stimulate the growth of blood vessels, which leads to tumor growth. Another study reiterated these findings, stating that opioids impact tumor cells in ways that encourage growth and metastasis.
As risky as narcotics are for chemically-dependent patients, patients taking them for the first time have an even higher risk. “Opioid-naïve patients, or those who do not take opioids regularly, have a lower tolerance to the drug and can overdose on a smaller amount. They also have a significant risk for chronic opioid use after surgery,” Dr. Rojas says.
Since Dr. Rojas and her colleagues implemented their study in 2017, the protocols have been used in several thousand lumpectomy and mastectomy procedures where patients were discharged without an opioid prescription. Increasingly, surgeons are successfully eliminating the need for these drugs without sacrificing pain control or increasing complications.
As part of the study, Dr. Rojas and her colleagues developed protocol guidelines to use before, during, and after surgery. These methods not only control pain without opioids, but they also restore patient “equilibrium” more quickly after surgery.
Before surgery, physicians counseled and educated patients about pain management. “We set patient expectations from the beginning to minimize the ‘unknowns.’ We said, ‘You will wake up after surgery, and you will not be in pain. We will give you these specific medications, so you will not need opioids,’” Dr. Rojas says. The team gave patients acetaminophen and gabapentin and allowed them to drink clear liquids up to two hours before the operation.
Surgeons infected long-lasting local analgesia into the surgical site during surgery, which kept the area numb for three days. They also administered additional non-opioid medications known as non-steroidal anti-inflammatories (NSAIDs).
What Dr. Rojas and her colleagues discovered
is good news for patients undergoing breast cancer surgery.
Patients in the group receiving opioid-sparing multimodal analgesia
reported lower pain scores than those in the control group.
Post-operatively, the team stopped IV fluids for the patients early to avoid fluid overload. Patients ate when they wanted and were encouraged to get up and move as soon as possible. Pain relief continued by alternating acetaminophen and ibuprofen. The patients were discharged from the hospital on the day of surgery or the day after without an opioid prescription. They were given a phone number to call if they experienced uncontrolled pain, although none called. By controlling pain through the protocols, the patients were discharged quicker. That’s even more important today. “In an era where patients are afraid to go to the hospital, these protocols get them home sooner and safer,” Dr. Rojas says.
Advances in surgical techniques also help reduce pain. Traditionally, a radical mastectomy removed the entire breast, lymph nodes under the arm, and chest wall muscles. Breast surgeons now use less invasive techniques, smaller incisions, and remove fewer lymph nodes. Physicians also prescribe chemotherapy before surgery to shrink tumors so that the procedure can be less aggressive.
At the UHealth Institute for Advanced Pain Management Center, Danielle Bodzin Horn, M.D., is one of the pain medicine physicians whose patients require relief when recovering from chronic pain conditions. “In a university setting, the patient’s health care team uses the latest best practices to do what’s best for their situation. We use many non-opioid modalities to relieve pain, including NSAIDs, anticonvulsants, antidepressants, interventional procedures (i.e., nerve blocks, ablations, etc.), and referrals to other specialists such as physical therapists and psychologists, just to name a few.”
The Center also includes an acute pain team who perform pre-operative and/or post-operative procedures to prevent or manage pain and limit opioid use for hospitalized patients undergoing surgery.
Talking to your surgeon about pain relief
Facing breast cancer surgery is hard enough. You should not feel intimidated about discussing opioid alternatives with your surgeon. “Everyone knows someone or has heard of someone addicted to opioids. Patients are seeking alternative pain relief options. This is a hot topic in the medical field,” says Dr. Rojas. The opioid-sparing protocols stemming from her study were published in the Annals of Surgical Oncology, the official journal of the American Society of Breast Surgeons, and are widely disseminated among surgeons.
The opioid epidemic ushered in a host of regulations designed to curb the problem, says Dr. Horn. “Doctors can still write a three to seven-day opioid prescription but are now required to take a Drug Enforcement Administration course before they can write a longer-term prescription. The scripts also require certain verbiage in order to be filled. As a doctor, that makes you stop and consider, ‘Are opioids really indicated?’ Doctors are aware and onboard to limit opioid use.” The Prescription Drug Monitoring Program (PDMP) must also be queried prior to prescribing opioids. This allows doctors to track filled opioid prescriptions and instances where patients use multiple providers and pharmacies.
Dr. Rojas encourages patients to discuss pain relief with their surgeon at their pre-operative appointment. Some questions to ask your surgeon include:
- How will you manage my pain after surgery?
- Will you discuss ways to minimize my pain with other members of your team, such as anesthesiologists?
- Do patients typically experience a lot of pain after the surgery I am scheduled to have?
- Are there non-opioid options to manage pain?
Physicians like Dr. Rojas and Dr. Horn are at the vanguard of a new era in pain management. As the protocols gain momentum among medical professionals, patients benefit from a better quality of life during and after treatment. As Dr. Rojas says, the patients themselves are pushing this trend. Working together with their doctors, they can help turn the tide on America’s opioid problem.
If you struggle with opioid use, call the private line of the UHealth Office Based Addiction Treatment program at 305-243-8523.
Nancy Moreland is a regular contributor to UMiami Health News. She has written for several major health care systems and the Centers for Disease Control and Prevention. Her writing also appears in the Chicago Tribune and U.S. News & World Report.
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