The Opioid Crisis plaguing North America, as well as many other corners of the World, is a complex and multifactorial process. Contributing variables to this crisis include susceptibilities to drug and alcohol dependency, the illicit drug trade, regulatory organizations encouraging aggressive pain management, patient expectations for a no-pain experience, and inadvertent over-prescribing of opioids by physicians and other prescribers. As a Pediatric Orthopaedic Surgeon, I have witnessed firsthand how post-operative opioid prescriptions can potentially send a young patient down a path of opioid dependency. As such, surgeons have a clear responsibility to be stewards of opioid prescribing. Here is the good news: the latest research has demonstrated that multiple evidence-based tools are available to surgeons prescribing post-operative pain management, including pre-, intra, and post-operative strategies.1
Pre-operatively, education is highly effective in counseling patients and guiding them to a pain management course less reliant on opioids.2 Pharmacologically, a combination of non-opioid medications has been shown to decrease intra and post-operatively pain experience.3 Specifically, a combination of acetaminophen, neuromodulating medications such as gabapentin or pregabalin, and non-steroidal anti-inflammatory medications have shown to be effective in reducing pain while also decreasing opioid use intra and post-operatively.
Intra-operatively, using local anesthetics as central blocks, regional blocks, and field blocks remain a workhouse for safe and cost-effective pain reduction intra and post-operatively.4 Regional blocks, particularly, have been well established in their effectiveness. However, using field blocks is often an underutilized yet simple technique. In particular, field blocks can preclude the need for any regional or general anesthesia, as demonstrated in “wide awake” hand surgery.5
Post-operatively, thoughtful opioid prescribing is critical to avoiding excessive opioid consumption. First, prescribing several opioids typically required for a particular surgery rather than prescribing broadly and non-specifically helps to avoid excessive postoperative opioid consumption.6 Second, multi-modal pain management is a simple and cost-effective technique to manage post-operative pain while also decreasing the utilization of opioids.7 However, central to this strategy is the consistent, rather than “as needed,” utilization of acetaminophen and anti-inflammatory medications as scheduled first-line post-operative agents to be used, with opioids being reserved for severe or breakthrough pain.
Surgeons are well positioned as stewards of opioid prescribing and pain management by educating and guiding patients and their families safely through their operative pain experience. Once surgeons assume this mantle, many evidence-based options are available to utilize. However, surgeons should assume this mantle of opioid stewardship actively and proudly.