Overprescribed Opioids After Surgery

Surgery is often a gateway to persistent opioid use. In this episode, Dr. Paul Sethi and Dr. Fred Muench share findings from the new Choices Matter Status Report, which examines opioid prescribing trends in the nation with a focus on the surgical setting.

Paul Sethi, MD is a board-certified orthopedic surgeon who specializes in sports medicine conditions of the elbow, knee and shoulder at Orthopaedic & Neurosurgery Specialists in Greenwich, CT, and President of the ONS Foundation. Dr. Sethi’s experience in treating sports-related pain ranges from weekend warriors to college and professional athletes. He is a leading research physician who speaks at academic and instructional medical conferences in the US and abroad. Dr. Sethi previously served as an orthopedic consultant to the Los Angeles Dodgers baseball team and was the former assistant team physician for the Los Angeles Lakers basketball team, Los Angeles Kings hockey team and University of Southern California football team. His research interests with the ONS Foundation include a focus on opioid-avoidant surgery.

Fred Muench, PhD is the President and CEO of the Partnership for Drug-Free Kids, a national nonprofit that supports families struggling with their son’s or daughter’s substance use. He is a clinical psychologist with extensive knowledge and understanding of substance use disorders, as well as a leader in leveraging digital platforms to help ensure that families who are dealing with substance use disorders have better outcomes. He is the Principal Investigator on research studies using technology to combat addiction and impulsivity, through current and previous grants from National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), and Robert Wood Johnson Foundation (RWJF).


Neal Howard: Hello and welcome to the program. I’m your host Neal Howard here on Health Professional Radio, thank you for joining us. Surgery is often a gateway to persistent opioid use with millennial women of greatest risk of becoming persistent opioid users. Joining us on the program today are Dr. Paul Sethi, he’s going to talk with us about some some findings from the New Choices Matter Status Report and he’s joined today by Mr. Fred Muench and they’re both going to talk with us about why surgery is a gateway to persistent opioid use, what is considered persistent opioid use and some options for pain management after surgery. Welcome to the program both Dr. Paul Sethi and Mr. Fred Muench, how are you both?

Dr. Paul Sethi: Great, thanks for having us.

Fred Muench: Good, thank you.

Neal: Well Dr. Sethi, a little background about yourself and then I’ll speak with you for a moment Fred, okay?

Dr Sethi: Thank you. I’m an orthopedic sports medicine surgeon. I practice in Greenwich Connecticut, I take care of youth athletes, weekend warriors and elite athletes. Part of my job is to fix problems like broken bones, torn ligaments and bad arthritis. And unfortunately, one of the solutions was surgery. In medical school and residency, we’re trained to treat your surgical pain afterwards with opiates, with narcotic medication as a first line. And unfortunately looking at our study, we tend to over treat that where patients are getting 90 pills for a rotator cuff or more than 100 for a joint replacement. There’s too many pills that I don’t think we’re thinking about the alternatives to opiates and using opiates is the second or third line and while we’re still thinking about them in our medical school practice which is probably not the most right way moving Forward.

Neal: Fred, what about yourself I know you you’re president of a non-profit? Talk about the Partnership for Drug-Free-Kids.

Fred: The Partnership for Drug-Free-Kids is a national nonprofit focused on supporting and empowering family members, particularly parents and caregivers to prevent and intervene with problems on substance use. And our focus is making sure that parents have the words, the  script and the information they need whether it be helping reduce binge drinking or when their child or family members going to a physician and maybe prescribed opioids or other medication that could lead to addiction.

Neal: Dr Sethi, we all understand how a person can get addicted to drugs, no, at recreational use maybe to escape something, one thing or another. But why is surgery a gateway to persistent opioid use? I mean you’re having surgery for a specific problem, your pain is because of that surgery and once the pain is gone you simply don’t take opioids anymore, but that’s often not the case. Explain why that is.

Dr Sethi: So you’re absolutely correct. I think we used to believe that you don’t get an addiction or a challenge, but these medications are unbelievably powerful and unbelievably addicting. So even after a short course of just seven days, you start to develop a dependence on it and your brain and your body trick you into thinking you need these medications. You may think you’re having pain because your brain is tricking you into it, but really you don’t necessarily need them. The idea for all of us and the message that I want to send is that perhaps we can treat pain because look, surgery does hurt. I would not be not telling the truth to say that it doesn’t  hurt, but perhaps we can treat that post surgical pain with non opiate alternatives in a lot of cases and for what it’s extremely painful like a knee replacement, we set a fixed expectation of how many pills you’ll need. In the same way you say, “Look you need to be on antibiotics for  seven days and then you stop, the infection is gone.” Well say to a patient “You need to be on the opiates for three to four days and then you stop. You’ll only need non narcotics after that.”

Neal: So it’s not like you’re trying to treat totally with non opioids. You’re at least getting the pain addressed initially and then managing it without opioids so as not to become dependent after the pain has subsided?

Dr Sethi: You said it exactly correctly and I believe that that’s a modern process because we would have believed a decade ago that “Look we’ll keep you on the opiates as long as you need to.” That’s unfortunately led to the crisis where we are now and changing the paradigm to say “Listen, the opiates are for the major paid for a fixed period of time, not to be refilled.” I believe it has to be the mantra that we take for, again, acute post-traumatic surgical pain.

Neal: Fred, Dr. Sethi he’s an  orthopedic surgeon, as he said he fixes problems, sports medicine. Kids are involved in sports quite a bit do you see any connection with kids and sports medicine and children being involved in this opioid epidemic when it comes to surgery for maybe a football injury or a track injury?

Fred: Sure. We know that when young people are prescribed opioids, that there’s a greater likelihood of addiction if those opioids are prescribed for more than even five days. A CDC report from 2017 showed the risk of opioid dependence increases significantly after even short-term prescription of opioid. So making sure that parents and caregivers and coaches are aware of the possible risks and consequences of prescribing opioids is a primary mission of  ours. And unfortunately, most people are not aware of it. They’re keeping opioids in the house, they’re not talking to their physician, so we have a lot of work to do but we’re moving in the right direction.

Neal: Dr. Sethi, The Choices Matter Status Report, what were some of the key findings? Maybe one key finding that you found to be most enlightening or maybe the most useful in combating the opioid epidemic?

Dr Sethi:  One of the things they keep fighting and combatting, I think as Fred alluded to, 90% of patients are going to want to hold on to those medications for fear of a rainy day or recidivation of their pain. This is absolutely a no and you have to get rid of medications, you cannot have them in the house. It represents a huge risk for misuse.

Neal: So what what advice do you have Fred for folks who maybe have some of these leftover opioids? What’s the proper way to dispose of them because a lot of folks are paranoid about just throwing them out in the garbage? Maybe somebody else will pick them up, maybe a stray animal will get them, you never know. What’s the proper way to get rid of them?

Fred: Yeah, there are proper ways to dispose of medications. You can go to Google and type in ‘drug take-back,’ ‘medicare safe medication disposal,’ the DEA has a website, there are other  websites that will find locations where you can dispose of medications properly. But I’d also say is the risk of keeping the medication is much greater than a pet or those medications being thrown in the garbage. As long as it’s done in a proper way where you’re wetting the medications, putting them in a paper towel, putting them in a bag or whatever it might be – the goal is to get those medications out of the hands of young people and immediate disposal is the best way to do it.

Neal: Dr Sethi, when it comes to initially prescribing opioids and then managing after surgical pain with non opioids, do you see a vast difference between that management when it comes to young people as opposed to the adults who may have the same type of injury?

Dr Sethi: I don’t think so. The important part is to start in the beginning with setting appropriate expectations, discussing with the patient, eliminating the fear of what pain is and letting someone know that “Look, surgery may indeed it may hurt and I’m going to help you take care of that pain and the pain doesn’t mean something is going wrong.” Once you set the appropriate  expectations and you create firm guidelines on how you’re going to do things, I think it becomes a more natural course. Patients really are scared of opiates. If you ask them, query them, one of the other things that our study finds is that they are worried, they don’t want to be on opiate medications. So by partnering with them, empowering them and letting them know that you’re  going to be there for them to help them through this event, I think you really buy in and you have a team approach – you and patient team approach – so it’s not only their surgical recovery but their pain management which is equally important.

Neal: Paul, I’d like you to give us a website where we can go and learn more about the about The Choices Matter initiative and then Fred, direct us online where we can learn more about the Partnership for Drug-Free-Kids.

Dr Sethi: The Choices Matter Campaign, so a lot of the data O told you about and information on how patients can empower themselves to better understand pain and non opioid alternatives is on the planagainstpain.com website.

Neal: Alright. Great, thanks.

Fred: And individuals can find resources at drugfree.org and they can also call our helpline at 1-800 drug free if their child or loved one is struggling with substance use.

Neal: Great. Dr. Paul Sethi, thank you so much for joining us today, as well Mr. Fred Muench, has been a pleasure speaking with both of you. Some great information and I’m hoping that we can talk again in the future

Dr Sethi: Thank you.

Fred: Great, thank you.

Neal: You’ve been listening to Health Professional Radio, I’m your host Neal Howard. Transcripts and audio of this program are available at hpr.fm and healthprofessionalradio.com.au you can also subscribe to this podcast on iTunes listen in and download at SoundCloud and be sure and visit our Affiliate Page at hpr.fm and healthprofessionalradio.com.au

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