Surgery, Without the Opioids With Dr. Sigman

New research has found that patients continue to be overprescribed opioids to manage pain after surgery. In fact, patients receive nearly 100 to 200 opioids following four common operations: rotator cuff repair, hip replacement, knee replacement and sleeve gastrectomy. Even more startling, 90 percent of patients with leftover opioids do not properly dispose of them, with many keeping the pills around in their homes and even sharing them with family or friends.

Dr. Scott Sigman, a board-certified orthopedic surgeon in Massachusetts specializing in sports medicine, is aware that orthopedic surgeons have routinely relied on opioids to manage pain, despite the availability of effective alternatives. He advocates for the use of non-opioid options to reduce, or even eliminate, the need for opioids during a variety of orthopedic procedures. Dr. Sigman has served as the team physician for the U.S. Ski Jump Team, has been the team physician at UMass Lowell for the last 20 years, and is the past Chief of Orthopedics at Lowell General Hospital.

We talked to Dr. Sigman about the role opioids have played in orthopedic procedures, and how effective non-opioid options can be utilized during surgery to reduce overprescribing and addiction risk.

New research shows that patients receive nearly 100 to 200 opioids to help manage pain following four common operations, three of which were orthopedic procedures. Why is opioid prescribing still so high?

It is eye-opening to see how many opioids are still being prescribed following common procedures like knee and hip replacements. As healthcare providers, it is imperative that we evaluate our prescribing habits and recognize that there are effective non-opioid options available to manage postsurgical pain. A recent national survey found that nearly two-thirds of surgeons report frequently feeling pressure to prescribe more opioids than they believe are necessary for their patients’ pain. Having these effective alternatives at our fingertips should alleviate any pressure to prescribe unnecessary opioids. In my practice, I utilize a non-opioid protocol for postsurgical pain that includes a long-acting numbing medication injected during surgery to help decrease or, in some cases, eliminate the need for opioids after surgery.

Research also found that 90 percent of patients with leftover opioids do not properly dispose of them, with many patients keeping the pills around the house and some sharing them with family or friends. How can surgeons help mitigate this and encourage safer opioid disposal?

The 2018 Choices Matter Status Report found that nearly one-in-five surgical patients admit refilling opioid prescriptions, even though they no longer needed the drug to manage their pain. With 90 percent of patients not properly disposing of their leftover medications, these statistics show there is a great risk for diversion of these opioids, which can lead to potential misuse.

As surgeons, we can help mitigate this is by prescribing the smallest number of opioids necessary for the shortest amount of time, and ensuring patients are educated on the proper ways to dispose of leftover opioids. For example, there are National Drug Take Back Days twice a year where temporary collection sites are set up around communities nationwide for safe disposal. Further, most local police stations are safe disposal sites and there are other options such as drug deactivation bags that can be used.

You’ve been passionate about offering your surgical patients non-opioid pain management plans for a few years now. How did you get involved in helping combat the opioid epidemic?

I have been working with the Choices Matter campaign for a few years now, which is designed to educate and empower patients to discuss non-opioid pain management options with their doctors.

When I was in medical school, they didn’t teach us about the addictive nature of opioids. However, over the past five or six years, I’ve really learned about the dangers of opioids and began to look into methods to reduce their use among my patients. I have also had the opportunity to treat patients who are in recovery from substance use disorder and do not want to risk taking any opioids. In fact, some patients even revealed they had been putting off surgery and living in pain due to the fear of potentially being prescribed opioids. Armed with this knowledge, I became passionate about offering opioid-sparing surgeries that do not compromise pain management and patient care.

As I began talking about my process of utilizing non-opioid options, I found that people were consistently coming up to me and sharing details of how they have been personally affected by the opioid crisis. This has solidified my commitment to minimizing opioid use at all costs. Now, every single patient I operate on receives a non-opioid option and minimal – if any – opioids following surgery.

As an orthopedic surgeon, many of the procedures you perform are elective. Do you find that patients put off surgery due to a fear of being in pain?

Yes, and I believe that is because there is a common misperception that recovery from surgery will be prolonged and painful. As a surgeon, I understand that no patient likes disrupting their daily routine due to a painful recovery process. That is why I encourage all of my patients to openly discuss their fears and past experiences with pain control with me prior to surgery. By setting expectations for what the recovery process will be like, and utilizing non-opioid options, we can help patients effectively manage their pain throughout their entire recovery process.

Are orthopedic patients uniquely at risk for receiving large amounts of opioids?

Yes, orthopedic patients are unique because they often have been living with pain for quite some time and sometimes put off surgery until the pain becomes unbearable. Because of this, many patients may already be taking opioids to manage their pain before they go in for a procedure. Prior opioid use may lead some orthopedic surgeons to prescribe higher doses or quantities of opioids after surgery. However, I encourage all surgeons, especially orthopedic surgeons, to educate themselves on the non-opioid options that can be used to treat pain just as effectively as an opioid prescription.

Are non-opioid options available for all orthopedic procedures?

Non-opioid options are available for many orthopedic procedures, as well as a variety of other surgeries. For instance, non-opioid options are used to treat post-surgical pain in C-sections, hysterectomies, wisdom tooth extraction, weight loss surgery and more. Patients should feel empowered to speak with their surgeons prior to surgery about a postsurgical pain management plan. There are great resources available to help patients facilitate a constructive conversation on pain management with their doctors. Visit http://shatterproof.org/choices-matter to learn more.\

Originally published in 2018.