Doctors Devise Safer Alternative to Opioids During, After Surgeries
It's been slightly more than a year since Jonathan Akindle, 23, underwent weight-loss surgery, and so far, so good.
He is now down 130 pounds, and he was able to get through gastric sleeve surgery and recovery without taking any opioids for pain.
"The pain right after surgery was more like a stomach ache. It was a little uncomfortable, but completely manageable," said Akindle, who manages a security firm in Long Island, N.Y.
There is a big push across all of medicine to find alternatives to opioids due to the nationwide opioid epidemic. Many people first become addicted to these powerful painkillers following surgery.
And the risk for addiction may be even higher for people who undergo weight-loss surgery. This is why guidelines from five medical societies, including the American Society for Metabolic and Bariatric Surgery, call for opioid-free or opioid-sparing pain relief during and after weight-loss surgery.
About 3% to 4% of people who receive opioids for the first time after surgery are still taking them a year later, and this jumps to 8% to 10% for people who had weight-loss surgery, said Dr. Dominick Gadaleta, chair of surgery at South Shore University Hospital in Bay Shore, N.Y.
Better pain relief
Instead of opioids, people undergoing weight-loss surgeries at Northwell Health Hospitals in New York receive intravenous acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) before surgery. This is followed by an intravenous infusion of non-opioid anesthetics and a nerve block of the surgical area. So far, surgeons at Northwell hospitals have performed more than 200 procedures using this protocol, including gastric sleeve surgery and hernia operations.
"We essentially turn the nerve endings down or off before surgery with preemptive acetaminophen or NSAIDs," explained Dr. Don Decrosta, chair of anesthesia at South Shore University Hospital, which is part of the Northwell health system. "When we get hurt or undergo surgery, the nerve endings in the injured area fire at a much higher rate, but if we blunt or eliminate this stress response with preemptive [pain relief], you get through the early healing days without the need for opioids."
Opioids block pain signals between your brain and body, while the new protocol is more targeted, he said,
People don't get sent home with a prescription for opioids because they don't need them, said Dr. Andrew Bates, director of minimally invasive surgery at South Shore University Hospital.
These folks aren't necessarily pain-free in the days following their procedure, and that's a good thing, Bates noted. "They may have some soreness afterward and that's OK because it's a major surgery and pain can give us important information," Bates said. "We never want to completely cover up pain."
In addition to a heightened risk of addiction and overdose, opioids cause many short-term side effects that can hamper recovery, including nausea, itching, fatigue, dizziness and constipation, said Dr. David Pechman, a bariatric surgeon at South Shore University Hospital. He is the surgeon who performed Akindle's gastric sleeve procedure in March 2021. Opioids slow down your intestines so you don't have bowel movements, but "with the new protocol, patients have regular bowel movements and are walking around the afternoon of their surgery."
When Pechman was in training, weight-loss surgery patients stayed in the hospital for two to three days. Now, most only stay for one night, and that is partly because opioids are not part of the mix any longer, he said.
People who undergo weight-loss surgery tend to be more susceptible to other opioid-related complications such as trouble breathing, nausea and vomiting, Pechman noted.
This can be a double whammy as weight-loss procedures may also increase chances of nausea and vomiting, he said.
For the most part, patients are on board with this opioid-sparing protocol. "Patients are very excited when they hear that they won't need opioids as they often know somebody who has been adversely affected or addicted to opioids, or have seen what opioids can do in popular culture and on the news," Pechman said.
It's catching on across the United States, too. Many other bariatric surgery centers are getting on board. "Sooner or later this will be standard of care," Pechman added
Many weight-loss centers are indeed developing their own opioid-sparing protocols, said Dr. Wendy King, an associate professor of epidemiology at the University of Pittsburgh's School of Public Health. "Efforts continue to determine the best way to limit or eliminate opioid use [during and after] bariatric surgery care," she said.
The American Society for Metabolic and Bariatric Surgery explains the different types of weight-loss surgeries.
SOURCES: Dominick Gadaleta, MD, chair, surgery, South Shore University Hospital, Bay Shore, N.Y.; Jonathan Akindle, security firm manager, N.Y.; Don Decrosta, MD, chair, anesthesia, South Shore University Hospital, Bay Shore, N.Y.; Andrew Bates, MD, director, minimally invasive surgery, South Shore University Hospital, Bay Shore, N.Y.; David Pechman, MD, bariatric surgeon, South Shore University Hospital, Bay Shore, N.Y.; Wendy King, PhD., associate professor, epidemiology, University of Pittsburgh School of Public Health, Pittsburgh
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