Over the past few months, many aspects of our daily lives have had to change or be put on pause due to COVID-19. Still, the opioid epidemic has continued to ravage communities across the country during this pandemic. The isolation, stress, and financial burdens of the crisis have significantly impacted our nation’s progress in tackling the opioid epidemic. Now, for the first time in years, reports are showing that opioid-related deaths are on the rise. Our nation has been dealing with two major concurrent health crises, which has put a significant strain on our health care system.

With many states re-opening, we find ourselves navigating a new normal. This includes changes in hospital and surgical center protocols, and other care facilities. It is expected that there will be a surge in patients undergoing elective surgeries within a short period of time to try and catch up with the millions of procedures that were postponed during the shutdown. Many of these procedures, which range from joint replacements to oral surgeries, are associated with high levels of opioid prescribing. There is genuine fear that as these procedures resume, there could soon be a burst of opioid pills in communities around the country, which could further exacerbate the opioid crisis in the nation.

Dr. Joe Smith, an anesthesiologist in Virginia, is committed to raising awareness about the importance of increased access to non-opioid options as a way to help minimize unnecessary levels of opioid prescribing for patients after surgery. While Dr. Smith utilizes non-opioids with his patients where he can, many health care providers struggle with a lack of access to these options, especially in the hospital outpatient setting. We recently spoke with Dr. Smith to discuss why access to non-opioid options is more important than ever, especially given the anticipated swarm of elective surgeries.

Have you seen an increase in surgeries in your state? What are you doing to manage that process?

Yes. Since the restriction on elective procedures was lifted in Virginia on May 1, we have been busy rescheduling patients who had to delay their procedures. We are also seeing new patients who are hoping to undergo surgery in the days ahead. The past few months have been unlike anything we have ever experienced, but as the Medical Director of Inova Loudoun Ambulatory Surgery Center, I am eager to be treating patients again and we are following a strict protocol to keep everyone safe and healthy. I anticipate a very busy few months!

We assume some patients might still have concerns about seeking medical care in light of the current pandemic. What can patients do to have a more positive surgical experience?

It’s understandable that patients might want to take extra precautions before scheduling surgery right now. Fortunately, there are steps they can take to have a safe surgical experience with minimal downtime during recovery. First, it is important to build a plan. This begins by speaking with clinicians about what to expect before, during, and after surgery. Setting expectations will help patients feel more at ease and confident about how their surgery and recovery will be managed.

There are a variety of resources and customizable discussion guides available to help patients navigate these conversations. This dialogue should include how your pain will be managed during and after surgery, as the pain management options chosen can directly affect a patient’s overall recovery experience. Ask your health care provider about your available options, including opioid alternatives.

Additionally, for anyone who may be feeling hesitant about unnecessary trips in public, telehealth appointments can allow patients to stay in touch with providers and ask any questions they might have leading up to a procedure.

As a health care provider, what are you doing to help improve recovery for patients during this time?

As an anesthesiologist, I have the opportunity to see individuals who are undergoing procedures for a variety of reasons. However, reducing or eliminating opioid exposure is a common goal for all of my patients. I provide my patients with a long-acting local anesthetic—essentially a numbing medication injected at the time of surgery—that provides non-opioid pain relief for the first couple days after a procedure, which minimizes the need for opioids. In many instances, my patients recover more quickly and have a better recovery experience. By reducing—or in some cases eliminating—opioid exposure we are also able to help patients reduce the unpleasant side effects (constipation, nausea, dizziness, etc.) that often come with taking opioids. I encourage anyone planning an upcoming surgery to speak with their health care providers about how they can get back home and to their everyday routine as quickly as possible.

Why is access to non-opioids important for patients?

Having access to a wide variety of non-opioid pain management approaches is important for clinicians, patients, families, caregivers, and the recovery community as a whole. We know that, given the choice, most would choose to manage their pain without the need for opioids.

Currently, I practice at two different surgical locations. At one, where I serve as the Medical Director of a same-day surgery center, I have access to non-opioid pain management approaches, which often allows me to provide opioid-free pain management to my patients. These patients frequently recover from surgery more quickly, suffer fewer adverse events after surgery and can return home faster after their procedure.

Unfortunately, when I practice in the hospital, I do not have access to as many non-opioid approaches, so the decision of how to manage a patient’s pain is hindered by a lack of treatment options. Many times, this is due to the fact that non-opioid medications are not as well reimbursed as opioids can be.

This must change and I’m glad that this has gotten the attention of legislators. There is currently legislation before Congress, called the Non-Opioids Prevent Addiction in America Act (NOPAIN Act) (H.R. 5172/S. 3067), that would change reimbursement policy to ensure expanded access to FDA-approved safe and effective non-opioid pain management approaches in all outpatient surgical settings.

How will increased access to non-opioid options affect the recovery community

While access to non-opioid options is important for all patients, this is especially critical for individuals in recovery who may need to have a surgical procedure. Patients in recovery may put off surgery due to fear of being exposed to opioids after actively avoiding these substances. These concerns are valid; we know that opioids come with a variety of side effects, including risks of dependence and addiction, even when taken in small quantities. Having the option to utilize non-opioids to manage pain following various surgeries helps remove this worry and allows patients to focus on getting back to day-to-day activities after their procedure. The NOPAIN Act would increase the availability of these options so patients do not have to put off a procedure for fear of pain or having to take opioids.

I have been working with Voices for Non-Opioid Choices to advance this legislation and I encourage anyone interested in learning more to visit their site.

What role does the surgical setting play in the overall opioid epidemic?

Surgery is often the first time a person is exposed to opioids. Research has found that some patients are prescribed nearly 100 to 200 opioid pills to help manage pain from four common elective procedures ranging from rotator cuff repair and hip replacement to knee replacement and sleeve gastrectomy. As mentioned, prescribing more pills than needed can result in opioid diversion. In fact, a 2017 report found that as a result of overprescribing in the surgical setting, 3.3 billion pills were left unused by patients. As an anesthesiologist, I find these numbers astounding and know that we can do better. Utilizing non-opioids helps eliminate these risks and can reduce the number of individuals whose lives are affected by opioid addiction or dependence.  

Do you find that other health care providers are interested in utilizing non-opioid options as well?

Yes. In fact, I frequently receive calls from my colleagues at the hospital telling me that they – and their patients – want to treat their pain using non-opioids for the many reasons discussed above. Unfortunately, for far too long, health care providers have been taught to treat pain with opioids; however, the status quo is changing and the opioid epidemic has given us an opportunity to do better, including becoming more responsible stewards of these powerful drugs. In the process, we can improve patient care as well!

I believe that non-opioid options are becoming more and more popular in the medical community as other providers see that patients are recovering effectively with minimal or no opioids following surgery. We now recognize that there are non-opioids that can be combined to treat pain such as acetaminophen, ibuprofen, and long-acting local anesthetics that provide patients with a positive, quick recovery.

Are opioid alternatives only available for certain procedures?

Non-opioid options are available to manage pain following a variety of surgeries, ranging from orthopedic procedures, C-section deliveries, wisdom teeth removal, cosmetic surgeries, weight loss surgeries and more. No matter what procedure a person may be having, I encourage them to speak with their health care professional about how their pain will be managed and what non-opioid options are available. Patients can educate themselves on their choices and prepare for surgery thanks to helpful resources such as shatterproof.org/choices-matter. The more patients are educated on alternatives and feel empowered to ask questions, the more awareness there is for the need for greater access to non-opioids.