Nonopioid Pain Management w/ Dr. Binetti

More than 228,000 weight loss (or bariatric) surgeries were performed in 2017. Like other major surgeries, weight loss procedures require a comprehensive pain management plan. Fortunately, doctors can now use non-opioid options to effectively manage a patient’s pain following surgery. This is especially important for women, as 80 percent of weight loss surgery patients are female, and research confirms that women are often prescribed more opioids than men. What’s more, women are 40 percent more likely to continue using these medications three to six months after their surgery, according to a recent report.

Dr. Brian Binetti, a bariatric and general surgeon in Rhinebeck, NY, has implemented a non-opioid approach to help his patients manage pain after surgery. Dr. Binetti has been a surgeon for 10 years and, as the director of Metabolic and Bariatric Surgery at Northern Duchess Hospital, has been a tremendous advocate for educating patients and providers about non-opioid options.

In an interview with Shatterproof, Dr. Binetti shared information about effective non-opioid pain management options, and how these alternatives are instrumental in helping patients recover from bariatric procedures.

Research has found patients undergoing a sleeve gastrectomy, a common bariatric procedure, receive an average of 194 pills to manage pain following surgery. Why do these patients receive so many opioids, and how do you avoid prescribing such a high volume for your patients?

Weight loss surgery is a major procedure for patients. Many patients also suffer from obesity-related health problems such as high blood pressure, sleep apnea, heart disease, and may already be on opioids to help manage other chronic conditions such as back pain. Since this procedure limits the amount of food the stomach can hold in order to lose weight, it’s very common for patients to experience discomfort after surgery and, therefore, opioids are often prescribed – perhaps in excess – to manage pain.

Fortunately, I’ve been able to limit the number of opioids I prescribe while still effectively controlling patients’ pain by using non-opioid options, including a long-acting numbing medication that I inject during surgery. This opioid alternative is extremely effective, as it provides pain relief those first few days after surgery when pain is often at its worst. This approach has also helped my patients avoid the unwanted side effects that accompany opioids, such as constipation, nausea, and dizziness.

Do you find more patients are expressing concerns about post-operative opioid use?

Yes. I’ve definitely noticed more patients are expressing concerns about opioids – likely due to the attention placed on the opioid epidemic across the country. Although patients may have concerns, we’re able to ease any reservations during our pre-operative meetings. During this time, I’m able to develop a relationship with my patient and address any apprehensions they may have, including how their pain will be managed after surgery. In addition, peer support groups are a key component to any patient who has weight loss surgery. These groups allow patients to hear firsthand how other patients responded to surgery and non-opioid options. When you hear that someone was awake, alert, walking around and didn’t even feel like they had surgery just hours after the procedure, it reassures patients that they can have this major surgery without relying on opioids to get them through the recovery process.

How has the opioid epidemic impacted your prescribing habits?

When I first became a surgeon 10 years ago, I used to prescribe a larger number of opioids after surgery than I do now because I thought that’s what patients would need and, importantly, I wanted them to be comfortable. Now, every single surgery I perform uses a non-opioid option, and that greatly reduces the need for me to prescribe high volumes of opioids.

Is there a specific process you have with patients when discussing a pain management plan and their need for opioids?

Yes, I have a discussion with each patient about the different medications we are going to use to manage their pain before surgery takes place. I take a multi-phase approach. First, we give patients non-opioid medications before they even go in to the surgery. During surgery, we use a special long-acting numbing medication to help keep them out of pain for a few days after the procedure. Post-operatively, we use non-opioid medications like ibuprofen and Tylenol to help control their pain as well. When I see my patients before they leave the hospital, we address their pain level and if they’ve needed any opioids thus far. If not, I don’t prescribe any opioids for them at home. We have found that using this approach has reduced our patient’s opioid use to an average of 0.3 pain pills post-operatively.

Do you find other surgeons are receptive to providing their patients with alternatives to opioids?

Physicians understand there’s a certain amount of responsibility that goes with prescribing opioids, as people can easily become dependent on these medications and they can easily be diverted and misused by others. In fact, we have found patients do not often use all of the pain medicine that is prescribed, and having lots of extra prescription pills around can be dangerous for families and communities. Fortunately, non-opioid options are becoming more accepted by the medical community and can help decrease, or completely eliminate, the need for opioids following surgery.

Are non-opioid options only available for certain procedures?

I started using non-opioids for bariatric surgeries, as we were trying to help patients get home faster and back to a normal routine, and the side effects of opioids can limit our ability to do that. When we realized we could reduce the number of opioids we used during surgery, while also helping our patients get back to normal quicker—getting them back on their feet, experiencing normal bowel function, and so on—we knew we had developed a successful non-opioid protocol that would greatly benefit patients. As a result, I now use this protocol on all my patients, including those undergoing general surgery procedures. I also know of other surgeons who successfully utilize non-opioids for C-sections, plastic surgery, orthopedic surgery, wisdom tooth removal and more. When you see firsthand how these alternatives can revolutionize the surgical journey and help patients in their recovery, you want to integrate them as much as possible.

No matter what procedure you’re undergoing, I encourage you to speak with your doctor before your surgery to outline how your pain will be managed. Patients can also educate themselves on their choices and prepare for surgery thanks to helpful resources such as shatterproof.org/choices-matter .