Medical Societies Have New Advice for Treating Surgery Pain in Patients Taking Opioids
/By Pat Anson, PNN Editor
The American Medical Association and 14 other medical societies have released new advice for physicians managing surgical pain in “complex patients” who have chronic pain, substance use disorders, or those taking opioid medication prior to surgery.
The seven guiding principles emphasize the coordination of pain care with other providers, and that patients taking opioids be allowed to stay on them before, during and after surgery.
“Every surgical patient deserves adequate pain relief that aims to prevent opioid reliance, chronic pain and other negative outcomes, but it may be more challenging to achieve this in certain patient populations,” Randall Clark, MD, President of the American Society of Anesthesiologists (ASA), said in a statement.
“The new principles were created to build upon an original set established last year during our first pain summit, but specifically address patients undergoing surgery with chronic pain, those taking opioids preoperatively, and those with substance use disorders. The new principles give the perioperative care team more guidance to care for these particularly complex patients.”
The new principles come at a time when many U.S. hospitals are reducing the use of opioids for surgical pain. As result, some people in pain have postponed or cancelled surgeries because they fear their postoperative pain would be poorly treated or their current opioid therapy would be disrupted.
For patients on long-term opioid therapy, the principles urge physicians to “continue the baseline opioid dose” and to provide “supplemental analgesia” for postoperative pain. The additional pain treatment should be the coordinated with the patient’s opioid-prescribing clinician, with the goal of returning to “the preoperative dose or lower as soon as possible.”
“This really is meant to be a patient-centered document that says we should invest in making sure these patients have a good experience,” said David Dickerson, MD, chair of the ASA’s Committee on Pain Medicine. “A lot of people don’t even get their baseline meds continued during their surgery. They don’t even get their home meds. And so this now creates a principle that says you need to have a really good reason why you’re going to withhold those meds.
“In our health system, if someone has pre-op opioid use, we know that they’re going to need more opioids in the wake of their surgery or they’re going to need more anesthetic even while they’re on the table having their care,” said Dickerson, an anesthesiologist who is section chief for pain medicine at the NorthShore University HealthSystem in Chicago.
In addition to the ASA and AMA, these medical organizations have adopted the new guiding principles:
American Academy of Orthopaedic Surgeons
American Academy of Otolaryngology-Head and Neck Surgery
American Association of Neurological Surgeons
American Association of Oral and Maxillofacial Surgeons
American College of Obstetricians and Gynecologists
American College of Surgeons
American Hospital Association
American Society of Addiction Medicine
American Society of Breast Surgeons
American Society of Plastic Surgeons
American Society of Regional Anesthesia and Pain Medicine
American Urological Association
Society of Thoracic Surgeons
‘CDC Guideline Falls Flat’
Dickerson emphasized the new guiding principles are only meant as a resource for physicians managing surgical pain and are not intended to be a guideline or standard of care. He also expressed concern about some of the proposed changes to the CDC’s opioid prescribing guideline, which now includes recommendations for treating postoperative pain.
“I think that the CDC guidelines, as they are proposed in their draft format right now, is not an incredibly functional document. It doesn’t really shape what great pain care looks like. All it talks about really is mitigating the effects of opioid injury. It offers up ideas, but I don’t think it’s a comprehensive summary of what we do for patients,” Dickerson told PNN.
The CDC’s draft revision is actually quite similar to the medical societies’ new principles for treating surgery pain. It allows for patients on long-term opioid therapy to get additional opioids “for the duration” of their postoperative pain, with a return to their baseline doses as soon as possible.
But Dickerson says there are many different types of surgery that require different forms of pain control, and some complicated patients may need more pain relief and different therapies than others. He thinks medical societies should set their own guidelines for their own specialties, and not rely on the generic advice of the CDC.
“I think that societies when they come together to do things like this are really best-tasked as experts to do this. To expect primary care physicians to write a guideline about how to manage surgical populations is limited from the start,” he said. “I think the CDC guideline falls flat.”
