Opioid-Free Surgery
Opioid-free surgery. In the news recently there have been multiple stories about Palestinian victims having to undergo surgery without the aid of anesthesia or opioids. Hospitals in Gaza are out of everything but patients in need. War, so it goes, as the late great Kurt Vonnegut would say. With these surgeries, some (maybe many) in the chronic pain community have been trying to equate the evils of war to doctors in this country who practice opioid-free surgery or opioid-free anesthesia. Since I’m all but guaranteed to have another neck surgery sometime in the next months, I wanted to take a closer look at this supposed opioid-free surgery that has some in the chronic pain community up in arms.
First, thanks to the evils of social media I should probably begin with answering who am I and why am I qualified to write such a post. For those of you who are new to my corner of the internets, I’ve had 11 surgeries with more on the way. The reason for my surgeries ranges from falling off a cliff rock climbing, to bilateral hip dysplasia, to my rheumatoid arthritis, atrial fibrillation, and my degenerative disk disease. If I remember correctly, the longest I’ve been under was around 3 hours and the shortest amount of time came during my right hip replacement surgery which was around 40 minutes. So far, I’ve not had any major side effects from surgery, but I have had some side effects.
In addition to multiple surgeries, I do use OxyContin daily. In fact, my bottle of Oxy is currently right next to my laptop as I write this post.
Despite my multiple surgeries and requiring Oxy as part of my pain management plan, I personally am grateful for every surgery and procedure I’ve had. I strongly believe and advocate that all surgery should be thought of as an opportunity for a better quality of life and if you are lucky enough to be able to consider surgery as a option, you should not be scared or even reluctant of surgery. Surgery should be celebrated, not feared. Yes, there is a quantifiable risk to having surgery. However, I don’t consider it a risk, in my eyes the risk is not having surgery and thus missing out on a chance to truly live.
Why do I think it is important to share my medical resume, for a lack of a better term, with you all? My perspective, otherwise known as my patient story, is only one side of the circle which is surgery. Those that are currently screaming the loudest in the chronic pain community think of surgery as a simplistic us (patients) vs them (surgeons and big medicine) proposition. Since there are some 60,000 surgeries performed in the United States daily, I want to make sure to leave space for the other 59,999 surgeries which a us vs them perspective doesn’t. I want to work with my care team towards a higher quality of life, I do not want to have to fight them.
So what exactly is opioid-free anesthesia you ask. In fancy sounding scientific speak, the primary goal of opioid-free anesthesia is to “abstain from the use of mu receptor agonists using non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, lidocaine, dexmedetomidine, ketamine, and low-dose glucocorticoids. In addition, regional nerve blocks represent a fundamental pillar of intra- and postoperative analgesia as part of the opioid-free anesthesia protocol.” Basically, it uses a combination of drugs to try and prevent our bodies from experiencing pain during surgery.
The purpose of surgery is to correct a wrong. In my case, my third neck surgery would be to correct the bulging disk and large bone spur I have a C3 that is causing both pain and neurological symptoms. Unfortunately, the act of surgery does cause trauma to our bodies. Anesthesia is designed to allow our surgeon access to our body to correct a wrong and to minimize our body’s reaction to the trauma of the act of surgery. By adding an opiate to anesthesia, the goal was to help our body’s register less trauma while we are asleep which in theory should help us recover quicker.
To help recover from the trauma of surgery, anesthesia also contains a drug that somehow wipes our memory of the act of surgery. Or that is the goal. If our body doesn’t know it has undergone a surgery then it has no reason to hurt is the logic, at least that is how it was explained to me by one of my anesthesiologists. Now, the drug that wipes our memory is not always perfect. Also, our bodies are very observant and can figure out on its own that something happened to us. Thus, the need for pain relief. Proponents of opioid-free surgery argue that surgical techniques have evolved to such level that we no longer need a strong opioid for pain relief, that a strong Advil or Tylenol can manage the pain without the risk of addiction or nausea or respiratory depression that comes with opioid use.
What can we do as patients. Since opioid-free basically anything has become a movement, answering what we can do as patients has become harder to answer.
Right now, there are some in the chronic pain community who think withholding information from our doctors is the most important thing we can do as patients. They believe that sharing information will put us at greater risk for being denied opioids as a surgical and/or treatment option. This is utter bull shit in my humble patient advocacy opinion and will put you in danger if you follow this advice. Regardless of the current political climate surrounding opioid-free surgeries, our doctors are only as effective as the information we provide to them. They can’t doctor if all we say is “I hurt”. Not only that, it is also unfair and unrealistic to criticize the medical profession as a whole if patients withhold critical information regarding what we are experiencing with our health. Patients should never advocate for other patients to withhold information; I don’t care what their personal story has taught them.
If possible, read all the patient stories you can possible find who have had the same surgery you need. When I say read all the patient stories, I mean the good and the bad. Too often, we only concentrate on the bad stories because they get the most attention or clicks. Just because Jennifer, who is a long-time advocate who you have followed years, had a bad experience with opioid-free surgery does NOT mean you will. Have respect for your own individuality, Jennifer is not you and you are not Jennifer.
By reading all the stories, you can steal the info that will most likely contribute to your success and better understand what questions you should ask your doctor before surgery. Asking questions is a useful tool for surgeons, their experience can help find answers that will put you in a better position for a higher quality of life. Based on my own experience, which includes surgery in 2 states and with multiple health systems, surgeons are arrogant because they can be. Their glory comes from getting you back onto the hiking trail, back to work, or back to living the life you want as soon as possible. They want your questions now because it makes their job easier, if they must assume info about you then that is where mistakes can happen. Questions are a positive thing when surgery is involved.
I’ve said this already, but it’s worth repeating. Before any surgery, ask questions. Talk to your doctor about your concerns. Ask your surgeon about anesthesia and whether they believe in opioid-free procedures. If your surgeon doesn’t feel comfortable talking about anesthesia, schedule an appointment before your procedure so you can meet with the anesthesiologist. On the off chance you can’t set up an appointment, request a consul with the anesthesiologist right before your surgery. Most surgeons, I’ve found, want you to feel comfortable and confident with the surgery plan, the plan including surgery and your recovery. Surgeons make great patient advocates; they want to help and have the necessary clout to break stupid rules if needed.
Here is the bad news and reality. Our healthcare system is still based on the economic principles of capitalism. Why is that bad news for us patients? Capitalistic systems give the right to businesses (ie surgeons in this case) to offer any services they want. That means surgeons might want to jump on the opioid-free bandwagon and only offer opiate-free procedures and care. We do have a right to fire doctors but that gets difficult in rural areas or if you are unemployed for example. Regardless, there might be cases where we will have to undergo an opioid-free surgery because there are no other options available in our area.
If an opioid-free surgery is truly your only option, everything I have talked about still applies. Ask questions. Drill your surgeon on their pain management methodology. Share with your surgeon all your other conditions, both physically and mentally. Let your surgeon and anesthesiologist know that you take opioids for your other conditions. Request a meeting with your anesthesiologist before your surgery, make sure you feel comfortable with them. Most importantly, be willing to work with your care team and don’t create a us vs them battlefield. Despite their perceived arrogance, surgeons and most anesthesiologists are big softies at heart which means they don’t want to see you back on their operating table or office again.
Time for the big conclusion. You ready?
Our country has an opioid crisis. The Sackler family screwed us with their criminal and grotesque greed, they wanted multi billions of dollars in their pockets simply for glory and didn’t care who got hurt in the process which started the crisis. This means opioids are going to be the devil for at least a generation, if not several. These are the PR facts, no sense fighting it. As chronic pain patients, there has never been a more important time for us to share our stories because of this crisis. We must all be willing to work together.
The main problem for patients is that there is a big difference between opioids as a political issue and opioids as a surgical issue. Surgery lives in the now, political issues live in future elections, but these two distinct time periods are blending into a big ball of confusion and frustration. Proof is in the advent of opioid-free whatever. Good people want to help end the crisis but there is no policy that can capture everyone. A perfect example would be this new opioid-free movement, some patients have already been hurt even though the goal is to prevent the opioid crisis from growing any further. Government isn’t committing genocide as some in the chronic pain community believe by implementing these new ideas, I know we live lives in pain but let’s keep the trauma rhetoric to a more realistic level.
All we can do as patients is make sure our doctors continue to see us as people and not political pawns waiting for the next election. We need them to know that we are people in need of surgical help. As patients, we must share all we can regarding our hurt, so our doctors have a complete understanding of our need. Patient centered care doesn’t mean we get to exclusively determine our care options. For example, any patient tweeting that they need dilaudid after what amounts to a 50-year-old routine neck surgery (saw someone tweet this recently), they are a patient with a drug problem and not a medical need. We must be willing to work with our doctors and not demand they give us dilaudid when it is not medically necessary. Asking “How might we” raises our quality of life, us vs them only makes more money for shareholders.
Finally, based on my research so far, no one should ever be done researching when it comes to medicine, opioid-free surgery is probably feasible, but I do not believe it is practical. What is the difference you ask. My chronic pain might be feasibly controlled by living on a nudist beach, eating pineapples, and drinking Coke, while dancing every third Tuesday after a full moon. Practically speaking, my chronic pain most likely will be controlled by taking my opioids, exercising, eating cleanly, while practicing meditation and breathing techniques. See the difference. The trouble is it might not be feasible or practical for some patients to find a doctor that isn’t swept up in this new opioid-fee movement. If that is the case, working with the doctor on all aspects of the surgical process is still the key to success I must believe. Care shouldn’t be determined by a popular movement; care shouldn’t be determined by the size of one’s checkbook either. The reality is care is too often determined in our country by forces constructed by others and not by the want of a higher quality of life.
P.S. If your doctor or someone on social media brings up the Michigan Open guidelines for surgery, make sure they know they are only for patients who are not currently on opioids. It states that very clearly on the Michigan Open website. If you are already prescribed opioids, their guidelines are NOT for you. I discovered this fact while doing research for this post.
