Non-opioid approaches to pain management: Here are the best alternatives.
After major surgery, the last thing anyone wants to deal with during their recovery is excessive pain. Of course, some post-op pain is usually inevitable, which is why pain management can have a big effect on the recovery experience of a patient. Not only does this make the recovery period more comfortable, studies have shown that successful post-op pain management can prevent long-term complications and shorten the recovery time.
There are many ways to control pain after surgery. Doctors may prescribe a number of different courses of action, including pain medication. Some of the most commonly prescribed pain medications are opioids.
Risks of Opioid Use
Now, lately the risks of opioid use and the epidemic that is gripping the United States has been written about ad nauseam. And for good reason, opioid use and their prescription should not be taken lightly. There are many dangers. Fortunately, there are also many ways to manage pain without opioids. And in the wake of the current opioid epidemic, more research is being done to explore better ways.
However, it must be said that opioids are a key pain management strategy for a post-op patient in significant pain. Opioids are quite strong, and therefore good at relieving severe pain, like those that may arise after surgery. There are many patients whose quality of life after surgery is improved dramatically with opioids.
However, patients must be well versed on the risks of opioid treatment. Since pharmaceutical companies began to push the drugs heavily in the 1990’s there has been an explosion of opioid abuse and opioid-related deaths. Opioids can be highly addictive. They are among the most abused drugs in the United States. Once addicted, withdrawal can be equally as debilitating as the original pain the drug was used to overcome.
In addition to high levels of abuse, overdose is a real threat. In 2016, almost 35,000 people died from natural and synthetic opioid overdose in the US. The mechanism of action is depressing the central nervous system, therefore they present the risk of vital processes such as respiratory rate dropping too low if the dosage is too high. Because of this and the relative strength of opioids, it is important for patients to be aware of the risks of opioid overdose.
Alternative and Multimodal Approaches of Managing Pain
Much has been made of the need to adjust our reliance on opioids for pain management. The NIH has established the Pain Consortium to research this issue and to find ways to manage those who are currently addicted to opioids. But most importantly, we are now realizing that there are other non-opioid approaches to pain management. It has also been found that opioids might not even be necessary for some surgery patients. And physicians are prescribing less and less numbers of pills to those who do receive them
As the opioid crisis is coming more into focus, health professionals are working to better educate patients on the risks/benefits associated with opioid use. This includes discussing pain management strategies, along with multimodal strategies, and giving patients the information they need to make the best decision for themselves.
Rather than prescribing opioids, some physicians are simply recommending weaker pain relievers or using them in combination with opioids to diminish opioid use. Non-opioid analgesics such as NSAIDs (Ibuprofen, aspirin, etc) and acetaminophen are often the first line of treatment. They are even turning to other types of prescription drugs such as steroids, anti-epileptics, and antidepressants. These types of drugs are typically less addictive than opioids and with much lower risk of overdose.
It is important to find interdisciplinary approaches to pain management, and not rely on prescription drugs alone. There are other ways to reduce pain that do not involve medication. Physical therapy is a great way to both decrease pain and increase muscle strength and flexibility after surgery. It can also be effective at reducing the chance of scar tissue and reducing the chance of re-injury.
Exercise therapy, for example, can be an effective tool for a pre and post surgery patient to manage pain, especially in older adults. It has been shown to decrease the risk of complications, increase functionality, and aid recovery, especially for high risk patients.
At this point we know pain is as much mental as it is physical. It is no surprise then, that many of the new alternative methods for non-opioid pain management revolve around mental health. And there is evidence that support these methods. Cognitive Behavioral Therapy (CBT) has been one of the most effective ways of providing support to patients. This model focuses on patient’s cognition and perception of pain, with the overall goal of changing the negative thoughts and behaviors related to it. This can lead to better pain outcomes and coping skills.
Yoga and meditation can be effective non-opioid tools. Restorative yoga can be great exercise for post-op patients. Unlike other types of yoga which can be a more intense, restorative yoga is much slower and gentler on the body, allowing patients to slowly work themselves back into an exercise routine without overdoing it too quickly. Like physical therapy, it can also be great for regaining flexibility. And in addition to meditation, it has been shown to potentially decrease recovery time after surgery.
Breathing exercises can provide an effective tool for pain management. Along with meditation, it provides a quick, easy way to manage stress and pain levels. Recovery can be an especially stressful time for the patient, so relaxing exercises such as these can be a great post surgery strategy. This type of exercise stimulates the vagus nerve, which leads to activation of the parasympathetic nervous system and dampening of the sympathetic nervous system. It sounds simple, but doing these breathing exercises effectively activates our rest and relaxation mechanisms and dampens our “flight or fight” response.
There are also “passive” ways to manage pain after surgery. One such example is a neurostimulator. While these devices are not found in the CDC guidelines for treating chronic pain, some evidence suggests that they may reduce chronic pain and reduce the need for opioid use. Some patients may be uncomfortable with an invasive procedure to implant the device, especially soon after a major surgery, but new technology has allowed manufacturers to develop smaller and better devices in order to encourage more widespread adoption.
Wound support devices can be effective at managing pain. For example, after a muscle is bruised, the standard treatment calls for using a support bandage as part of the RICE method. Support bandages help immobilize and protect the area as well as reduce swelling. In a similar way, using a purpose designed support device after major surgery provides many potential benefits including providing support, pain relief, decrease inflammation, and encourage movement.
After chest surgery for example, an external chest support has been shown to not only decrease pain, but also reduce the risk for post-op complications. They have even been shown to possibly reduce readmission rates after surgery.
Abdominal binders are another example of post surgery support that can provide pain relief. They provide support after surgical interventions in the abdominal organs, as well as a caesarean section, tummy tuck, or a hysterectomy. In addition to providing support and pain relief, they can also help promote deep breathing and mobilization. Thus, they be of even more benefit when combined with the relaxing breathing exercises which we mentioned earlier.
As we have seen, there are a number of safe, non-opioid, ways to help manage pain after surgery. From other types of medication, to physical and mental therapy, to body supports, or any combination of these methods, there is no shortage of strategies to help patients find pain relief and improve quality of life. And more ways are being explored as we are starting to realize the gravity of the opioid epidemic that we are in the midst of. Hopefully all of this in the end will lead to safer pain management and post-surgery outcomes for current and future patients.
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External wound supports have not yet been considered as standard adjunctive therapy in ERAS protocols. Yet, they could very well be an important complementary treatment that easily fits into the fast track regimes. In addition, they could help patients to be more compliant with the activity protocols in the hospital and at home.