June 2021 – Optimizing Pain Prior to Surgery

This month Iwas honored to participate in the Royal College of Anaesthetists’ Faculty of Pain Medicine Webinar on Perioperative Pain Management (my section begins at 2:37).Specifically I was asked to speak on what we’ve been trying to accomplish locally (as well as nationally) in terms of reducing preoperative opioid use to improve elective surgical outcomes.

The title of the talk was “Preoperative Opioid Weaning”, which was the topic assigned to me specifically, based on previous research publications.  This issue has become a big deal over the past decade or so, as increasing evidence shows that chronic use of opioids prior to surgery is usually a bad idea.  Study after study after study shows worsened outcomes in terms of the actual operation itself, but also the hospital stay itself, with significantly increased complication rates ranging from worsened pain control after surgery to death.

What we’ve learned though over the past decade, and what I tried to highlight in this presentation is the fact that simply weaning off of opioids prior to surgery isn’t good enough.  There are always other issues at play here, with some of the most common being severe sleep deprivation (which also worsens surgical outcomes tremendously by impairing the healing process), poor dietary and mobility patterns (which also worsen surgical outcomes), tobacco use (which we’ve known for decades worsens surgical outcomes) and in many cases unhealthy anxieties and other psychological factors.

These issues all need ‘optimization’ prior to committing to elective surgery, or, as we’ve seen increasingly this century, going to the operating room to try to fix the perceived underlying problem (like a rotator cuff tear, an arthritic knee, or a herniated disc) often backfires, with worsened pain and dysfunction afterwards.  And back to the opioid issue, not only has it been proven now that preoperative opioids worsen surgical outcomes, we are now starting to see the converse, namely that reduction of opioids – even by only 50% - can significantly improve outcomes.

So, to recap, getting off of opioids before surgery is a good idea.  But it’s usually not as simple as it sounds; there’s a lot to that equation and to the bigger picture.  If elective surgery is something you are considering for a pain problem, we’re happy to discuss all this with you in person.