Postoperative Pain and the Decreased Need for Opioids

As a pilot, pharmacist, and human being, I am asked what-if questions. In the past four months, the most common scenario is, “I am having a surgical procedure in two weeks, and I am apprehensive about getting narcotics for pain control post-procedure. 

What if I get addicted and cannot get off the opioids prescribed after I leave the operating room?”  No worries, my friend and I have the data to allay your fears and trepidations.

Healthcare providers that provide pain management services include physicians performing the interventions and surgeries, physician assistants (PAs), nurse practitioners (NPs), and pain management pharmacy specialists. In addition, professional pain societies, governmental agencies, and accrediting bodies oversee opioid use in the U.S. and the world.

The mid-’90s through the early 2000s saw a big push to increase the use of opioids for inadequate pain management for patients (Ann Intern Med. 1990 Dec 1; 113(11):885-9). In 1995, the American Pain Society (APS) started the Pain as The Fifth Vital Sign campaign. This campaign recommended that physicians and health systems expand their use of pain treatments, including opioid analgesics (Campbell JN. 1995 APS Presidential Address. Pain Forum1996;5:85-88).  In 2001, The Joint Commission (TJC), which accredits hospitals, published pain standards for all the hospitals.

The pathophysiology of post-procedure pain is both neuropathic and somatic or visceral. Neuropathic pain affects the neurons, and any trauma to the peripheral nerves will cause neuropathic pain. Bodily pain involves A-beta fibers found in cutaneous and deep tissue. Visceral pain involves C-fibers found in the viscera and connects to the spinal cord via an afferent pathway to the brain. The brain interprets these specific signals as pain. These particular sites are pain management targets.

In one study, patients described post-procedure pain as either moderate or severe 75% of the time (Niger J Clin Pract. 2019 Apr;22(4):478-484). Less than 50% of surgical patients report adequate pain control post-operatively (J Pain. 2016 Feb;17(2):131-57). This scenario may require an increased dose of the opioid that could increase the risk for chronic opioid use due to chronic pain caused by the procedure.

The goal for the pain management team is to tailor the dose of the pain management to reach a pain-free state, transition from opioids to non-opioids while recuperating, strengthening, and getting the patient back to their baseline state of being.

The most commonly used pain medications used post-operatively are opioids, non-steroidal anti-inflammatories (NSAIDs), acetaminophen (TylenolÒ), gabapentin (NeurontinÒ) or pregabalin (LyricaÒ), steroids, IV ketamine, and IV lidocaine.  Every hospital or outpatient surgery clinic will have perioperative, intraoperative, and postoperative pain protocols. The proceduralist will have a pain order set that lists each category of pain medications available for pain control. The patient will have available for administration, based on their pain score, around the clock, and “as needed” pain medications.

The IV opioids available and most often prescribed are IV morphine, hydromorphone (DilaudidÒ), and fentanyl. The first 24 hours post-operatively are the most critical to controlling a patient’s pain.  The goal is patient comfort and transitioning to oral opioids as soon as possible. The next step, upon discharge, is to prescribe only enough oral opioids for 5-7 days with no refills. The 5- to 7-day opioid dose and frequency should be tapered over the designated duration as well. As the amounts of opioids are tapered, acetaminophen (TylenolÒ) is administered around the clock. Typical dosing regimens of acetaminophen are 500 – 1000 mg three to four times a day, not exceeding 4000 mg (4 grams) daily. By the fifth or seventh day post-discharge, the patient is only using acetaminophen for pain. The patient should be seeing the proceduralist a week after discharge for postoperative evaluation for pain and healing.

The oral opioids options for post-operative pain include hydrocodone/acetaminophen (VicodinÒ) and oxycodone/acetaminophen (PercocetÒ). The pharmacokinetic and active metabolite profile of hydrocodone and oxycodone play a role in adverse side effects. The synergistic profile of added analgesia may cause toxic effects such as respiratory depression, especially in an obese patient with a BMI of > 30 kg/m2.  The plasma half-life of hydrocodone/acetaminophen and oxycodone/acetaminophen is 3-9 hours. Five times the half-life (FAA criteria) for when the medication would be out of the circulatory system is 45 hours.

Here is where the true pharmacokinetics of hydrocodone and oxycodone differ. A prodrug is a medication that has active properties before being metabolized and, when broken down by the liver, produces a metabolite that has active properties. Hydrocodone is a prodrug that is metabolized in the liver, and the liver breaks down hydrocodone to norhydrocodone, an active metabolite. Oxycodone is broken down in the liver to oxymorphone (OpanaÒ). Each prodrug and metabolite will take 1 to 3 days to be eliminated from the body. When I counsel patients, I highly encourage them not to drive for 7 days. My recommendations would be 10 days after the last dose of opioid medication before a flight for pilots.

NSAIDs that are prescribed post-surgery are IV Ketorolac (ToradolÒ) and celecoxib (CelebrexÒ). Ketorolac and celecoxib are potent anti-inflammatory and pain reducers. Celecoxib can be used synergistically with IV and oral acetaminophen and gabapentinoids. Gabapentinoids are anti-seizure medicines that are also used for peripheral nerve pain. Gabapentin (NeurontinÒ) and pregabalin (LyricaÒ) are examples of gabapentinoids used in postoperative pain management.

In 2001, a program called Enhanced Recovery After Surgery (ERAS) used non-opioid pain medications and opioids (multi-modal therapy) and showed decreased opioid use. Preoperative acetaminophen, celecoxib, and gabapentin are administered. Post-operatively, celecoxib, gabapentin, and acetaminophen are given for a short time with opioids. ERAS decreased opioid usage and reduced the risk of chronic use or misuse of opioids. Opioid side effects, such as sedation, nausea/vomiting, ileus, and respiratory depression, were all decreased, (Can J Anaesth. 2015;62:203–218).

A pilot faces many critical decisions in the air and on the ground. If you have a surgical procedure scheduled, a key outcome criterion to consider is your pain management regimen upon discharge. Except for acetaminophen, opioids are not on the FAA-allowed medications for pilots list. I recommend weaning off opioids over a 5- to 7-day period upon discharge and not flying for at least 7 days and preferably 10 days after the last dose of opioid taken.  NSAIDs and acetaminophen are medications that will reduce your pain. Exercises recommended by the institution’s physical therapist will play an essential role in your speedy recovery and decrease pain medication usage. Be safe and fly well. 

Larry M. Diamond, PharmD, CFII

Larry Diamond has a Doctor of Pharmacy Degree and has been a pharmacist for 37 years. Larry’s pharmacy practice has been as a Clinical Pharmacy Specialist in Cardiology, Orthopedic Surgery Specialist and most recently Clinical Pharmacy Coordinator. He is a CFII, a pilot for 33 years and has been an AOPA member since 1984.

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