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Archive Anesthesia 2017

Surgery's Role in Slowing the Opioid Epidemic

Q&A with TJ Gan, MD, MBA, MHS, FRCA, internationally known post-pain management expert.

Tong Gan, MD, MBA, MHS, FRCA


Was it a mistake to label pain the 5th vital sign?
Back in 2001, when The Joint Commission called pain the 5th vital sign, caregivers increased the use of opioids to ensure patients felt no discomfort. What they failed to understand at the time is that patients will accept experiencing some level of post-op pain. According to one of my previous studies, surgical patients overwhelmingly said they would rather tolerate some pain instead of enduring opioid-related side effects.

How much are surgical facilities contributing to the problem?
A recent study of health insurance claims showed that patients who underwent 11 of the most common types of surgery were at an increased risk of chronic opioid use. Most surgeons and anesthesia providers are unaware of the opioid abuse epidemic that's impacting countless communities. The culture of care is also partially to blame. Patients who are in pain believe they should receive strong painkillers such as opioids. If they don't, they think their pain can't be effectively managed.


So patients need to alter their expectations?
That's part of the problem. There are also many physicians who are still unaware of alternative therapies — acetaminophen, IV NSAIDs, local anesthetics and gabapentin — that reduce the amount of opioids patients need. Physicians also tend to overprescribe opioids. They write scripts for 30 to 60 days of therapy when in reality most post-op pain improves after a week. Many patients don't finish their full prescriptions and the extra pills are left in medicine cabinets. That certainly contributes to the abuse potential.

Isn't prescribing opioids easier than multi-modal pain management?
That's true, to a degree. Physicians tend to overestimate how much pain medicine patients need after surgery and don't want to be bothered by patients complaining of discomfort. Instead of writing scripts for a week's worth of pain pills and requiring the patient to call in for refills as needed, they prescribe a longer regimen, regardless of whether it's needed.

Is the outpatient evolution helping to limit the use of opioids?
Absolutely. Providers must consider alternative non-opioid based therapies to provide pain relief without risk of PONV and sleepiness, so patients are ready for discharge hours after surgery. Several complex procedures are moving to the ambulatory setting and more could follow if we continue to develop analgesic options that don't cause significant side effects.

Dr. Gan ( is professor and chairman of the department of anesthesiology at Stony Brook (N.Y.) University.

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