Crossing the Pain Threshold

A pain-free recovery from surgery certainly sounds appealing, but where should doctors draw the line when prescribing opioids? Should a patient being discharged after minimally invasive outpatient surgery be prescribed the same number of painkillers as a someone who underwent a total knee replacement? Are there alternative, non-opioid treatments that could replace these addictive compounds?

As opioid addiction reaches epidemic proportions in the U.S, killing approximately 130 people each day, doctors are increasingly asking these questions. Studies routinely point to postoperative surgical opioid use as a gateway to overuse and addiction. With about 50 million surgeries performed each year, including invasive and non-invasive procedures, about 80% of patients are prescribed opioids to manage pain. Some 2.6 million of them become persistent, long-term users of opioids, according to a study published in JAMA Surgery by Brummet et al. In a separate study published in JAMA Surgery, many surgeons were found to overprescribe opioid painkillers to patients by four times the necessary amount.

“Recognizing the significant role that postoperative pain management and the surgical setting can play in fueling the epidemic is crucial in the development of strategies to prevent the development of drug tolerance and addiction,” notes a new white paper published by Heron Therapeutics, a biotechnology company based in San Diego. The paper outlines some of the risks of opioid use after surgery, including adverse drug events, tolerance and addiction, and points to some possible solutions.

Dr. Roy G. Soto, the author of the white paper and director of education and the anesthesiology residency program for the Beaumont Health System, says: “using non-opioids as the foundation for acute postoperative pain management, along with expectation management will yield significant improvements”.

Before surgery, Soto says doctors and patients should have a discussion to outline the use of non-opioid medications and the expectation that pain is normal and its nature and intensity will change over time. “Postoperative pain is different than pain you experience in normal life,” Soto says. “That is why it is important for patients and their doctors to discuss pain treatment options, including ones that do not involve opioids.”

Soto notes that a combination of non-opioid medications could also be used together before, during and after surgery, to help reduce pain in recovery, thereby reducing the need for opioids.  “Local anesthetics that block pain signals from reaching the brain, anti-inflammatory medications (NSAIDs or steroids), acetaminophen, and medications that protect your nervous system (gabapentinoids) should all be part of the combination of treatments used to control pain and lessen side effects after surgery,” Soto says.

Heron Therapeutics recently received priority review designation from the FDA for its investigational drug HTX-011, the first and only dual-acting local anesthetic, which combines bupivacaine with a low dose of the nonsteroidal anti-inflammatory drug (NSAID) meloxicam in a novel extended-release Biochronomer® polymer. The drug, when applied to the surgical site non-intravenously, is intended to overcome the challenge of acidity to help manage postoperative pain through 72 hours and reduce the need for opioid analgesics.

In a recent pain management study of patients who underwent hernia repair surgery and received HTX-011 alongside a regimen of generic over-the-counter oral analgesics, 90% of subjects did not need opioids in the 72 hours following surgery and 81% remained opioid-free for 28 days.

Whether through consultation or medication or both, “It is clear that the pendulum of pain management has swung towards opioid reduction,” Soto says.

Published by: https://www.scientificamerican.com/custom-media/crossing-the-pain-threshold/?mvt=i&mvn=a01141bcc3634f67bd5ef184cdad1fd2&mvp=NA-SCIEAMERLIVE-11237933&mvl=TopicAgenda

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