THE QUESTION
I'm going to have surgery soon and I have been told I will be given an opioid medication to control the pain after the operation. But I see stories of people getting hooked on opioids all over the news, and I'm scared to take them. Am I right to be worried?
THE ANSWER
There is a very real problem with the inappropriate use of opioids. But such concerns need to be kept in perspective.
The first thing you need to know is that opioids can be extremely useful in the management of acute or short-term pain – especially in the days immediately after surgery.
In fact, uncontrolled pain can hinder a patient's ability to recover from an operation, says Dr. Asim Alam, an anesthesiologist at Sunnybrook Health Sciences Centre.
Opioids enable patients to get up, move around and begin the rehabilitation process. The goal is to use the drugs for the shortest time possible.
Problems can arise when patients end up on the drugs for longer than is necessary. Prolonged use can lead to tolerance, which means the patient needs higher and higher doses to get pain relief. The higher doses, in turn, increase the risk of side effects including drowsiness, nausea and severe constipation.
Alam says opioids should not be used as a first-line treatment for chronic pain. And yet, prescriptions for opioids, including for chronic conditions, have jumped by 70 per cent in Canada since 2008.
Alam says some of the pharmaceutical companies are partly responsible for the skyrocketing use of opioids.
Among other questionable marketing and sales practices, he says, the firms led well-meaning physicians to believe that the newest formulations of their products were safe to take long term for chronic conditions such as osteoarthritis of knees and hips, persistent backaches or neuropathic (nerve) pain. With the opioid epidemic, there's now a growing realization that the drugs are not as safe as they were portrayed.
When used appropriately, however, they can play an important role in a patient's recovery from an operation, says Alam.
Short-term opioid use is unlikely to result in addiction for the vast majority of patients undergoing major surgery, says Dr. Hance Clarke, director of the pain research unit at the Toronto General Hospital.
He co-authored a study that looked at 39,000 patients who had never taken opioids before their surgeries. Half of them left hospital with a prescription for opioids. Three months later, only 3 per cent of them were still taking the drugs.
A follow-up study revealed that just 0.4 per cent of patients continued to receive opioid therapy a full year after surgery. This works out to one in every 225 patients.
Clarke says this research should provide some reassurance to surgery patients who are reluctant to take opioids.
Even so, he believes the medical community should never be complacent about addiction. Although an individual patient's risk is extremely low, a lot of people still get into trouble when you consider that millions of major surgical procedures are performed worldwide every year.
The best way to avoid potential problems is to identify those patients who are most likely to develop an inappropriate reliance on opioids.
Recent studies provide clues about who might be at an elevated risk of staying on opioid medication long term. In particular, research shows that some surgeries tend to cause more discomfort than others and may lead to persistent or lingering pain long after the operation. As a result, patients may feel the need to keep taking an opioid.
For instance, thoracotomy surgery – in which an incision is made in the chest to gain access to the lungs or other organs – can cause prolonged pain. Amputations can be problematic, too. "Whenever you damage nerves, the risk for a persistent pain problem increases significantly," says Clarke.
Certain psychological factors – such as anxiety or depression – tend to increase the odds of a patient developing persistent pain.
Furthermore, people with a history of substance abuse and those who are already taking opioids, face an elevated risk of opioid misuse following surgery.
Dr. Clarke says high-risk individuals should be singled out for special attention. That might include offering them other ways to manage pain, such as non-opioid pain relievers or mindfulness training.
Unfortunately, some vulnerable patients don't get the help they need. Once discharged from hospital, their care often shifts to a family physician who may be ill-equipped to deal with their pain, and could renew or even increase the dosage of the opioid prescription originally provided by the surgeon.
To further complicate matters, people have different pain tolerances. Some may need more pain medication than others.
Patients should also be aware that physical dependence on opioids is common. Dependence is not the same as addiction. It simply means you will potentially experience withdrawal symptoms, such as diarrhea and abdominal pain, if you stop opioids abruptly.
Make sure you know how to gradually wean yourself from the drugs. If you're having problems, ask a health-care provider for a plan to get off them.
Paul Taylor is a Patient Navigation Advisor at Sunnybrook Health Sciences Centre. He is a former Health Editor of The Globe and Mail. You can find him on Twitter @epaultaylor and online at Sunnybrook's Your Health Matters.