Episode 4: Top 5 Things Your Surgeon Wants You to Know

Opioid Conversations with Surgeons

Today’s episode titled top 5 things your surgeon wants you to know features Dr. Scott Cowan, a cardiothoracic surgeon and associate professor at Thomas Jefferson University hospital and Dr. Matthew Philp a colorectal surgeon and associate professor of clinical surgery at Temple Health. Both Dr. Cowan and Dr. Philp also serve as clinical advisors for the PENNJ-SOS program. Today’s episode is also moderated by Pamela Braun, MSN, who currently serves as the Vice President for Clinical Improvement at the Health Care Improvement Foundation.

Pamela Braun: Dr. Cowan and Dr. Philp, I want to begin by thanking you for joining me on today's podcast. As you know, you were each asked to come up with a list of the top things you want your patients to know about opioids and pain management when they need to have surgery. I have your lists, and I think you both provide some really great advice for patients. One of the things you both listed is the importance of having a conversation with your surgeon about pain management. Dr. Philp, we'll start with you - can you tell me why a conversation is so important?

Dr. Matthew Philp: Thanks, Pam. I'm really happy to be here and speak with you and Scott today. Having a conversation is huge, because it just sets all the expectations with you, and with your surgeon and the patient. There’s a wide range of operations that we do. We have the insight of what recovery will be like, what expectations are—because a lot of times we see that, where they say, “I've seen someone that's had that procedure”. And they have this set expectation of how things are going to be. Especially if it's something that may have happened 15-20 years ago, when management was different. We had different options. We didn't do things the way we do today. We do things better, and recovery can often be faster. For example, using something like minimally invasive or laparoscopic surgery for major abdominal cases. The recovery is just so much different and better for patients, so they expect sometimes to have all this pain and it's not going to be like that. Having that conversation is just so huge. Setting expectations from the get-go is really important. Answering the questions that patients have is really important.

Pamela Braun: Thank you. And perhaps also the question for you, Dr. Cowan, is that at what point should these conversations happen with the surgeon?

Dr. Scott Cowan: Thank you for inviting us to participate in the podcast, Pam. It's great to be here today. I think it's always important to have those discussions about pain at the time that the patient's scheduling their surgery, really to help set those expectations that Dr Philp mentioned. And also to talk to and educate the patient's family members about what to expect in terms of potential side effects with the patient and any potential long term consequences of being on these medications. One of the most important things a surgeon can do is to let their patients know that having some pain after surgery is completely normal and is to be expected. So, the goal isn't to completely eliminate their pain, but really to make it so that they can function and get through that acute phase, those usually two to three days after surgery, where the pain is the worst. And that's where opioids really play the largest role nowadays.

Pamela Braun: Really a great point. Thank you. Dr. Philp, you mentioned in your list that it's also really important to develop plan with your surgeon. I wonder if you can elaborate a little bit about that?

Dr. Matthew Philp: Yeah. So I think having a good plan is important. We're talking about opioids here today, but opioids really should only be a part of a total pain management plan. I think one of the things we're doing—I mentioned things we do differently now than we did 10 or 15, even five years ago—is incorporating other modalities of pain management. Nonsteroidal drugs, ice, elevation, even some cognitive therapies… there's a whole spectrum of things that you can do. And it's going to vary by surgeon, by procedure, by patient. The more information we know about the patients, their histories, their prior experiences, the better we can tailor a plan. It really shouldn't be a one size fits all approach to pain management. It's best when it's done with some thought and nuance to the particular patient.

Pam: Great. That's really helpful, because postoperative pain is unique for every individual. So, I think that is nicely aligned with exactly what you were just saying: truly tailor that plan to the unique needs of the patients. Dr. Cowan, for patients that have an opioid use disorder, or may have struggled with addiction in the past, should they bring that up with their surgeon before surgery?

Dr. Scott Cowan: Great question. And absolutely. And it's important that the surgeon knows this beforehand so that a plan can be made with the surgical team, with the anesthesiologist, with the nurses. In terms of, again, setting expectations for the patient, letting them know what to expect after surgery… There are other conditions also that are important to determine, and these include whether there's a history of a patient being anxious a lot, has a depressive disorder, and other factors that do contribute to the amount of opioids that are requested or required after surgery. So, very important that this conversation occurs, really, again, at the time of planning surgery so that the best care can be taken of the patient.

Pamela Braun: Another point you each made that you wanted patients to know is that opioids can be prescribed and used safely after surgery. I think some patients are really afraid about taking opioids and perhaps getting addicted. Can either of you maybe describe why using opioids after surgery can still be a good option for patients?

Dr. Matthew Philp: Yeah, I do think that they do have a critical role and an important role for pain management, especially for things that we do that cause more pain. I think as Dr Cowan mentioned, we can't eliminate it, but we want people to be functional. That's the most important thing. For example, if you have abdominal surgery and you have so much pain you can't breathe and you end up with pneumonia, that's not a good outcome. So, we really do need to manage these things, and opioids can be very effective at doing that. It's important to use these things appropriately.

Pamela Braun: Thank you. Dr. Cowan, as a cardiothoracic surgeon, I'd be interested in your perspective on how to make opioids and the prescription of opioids and the use of opioids safe for patients.

Dr. Scott Cowan: I agree with what Dr. Philp mentioned, that opioids, although we're trying to decrease them as much as possible, they do at times play a role in helping people get back to that functional status. Just a couple key points that we like to remind our patients of, and that it's always important to take the lowest dose possible for the shortest amount of time to help avoid the side effects of opioids. And typically, opioids are reserved for what's considered that breakthrough or severe pain that's not adequately controlled by ibuprofen, Tylenol, or other non-opioid medications that are given after surgery. That these pills should never be crushed because if they are crushed, they can be absorbed faster and can lead to an overdose. Finally, opioids should never be taken with medications such as sleep aids or antihistamines or muscle relaxants, alcohol—you can have serious side effects. So, those conversations should really happen with the surgeon and the patient to make sure that patient is aware of those dangers, if you would, of opioids.

Pamela Braun: Really great points. Thank you. I think you really addressed another question, about what steps can be taken that can make opioids a safe option, either by the provider or by the patient. Dr. Philp, if you have anything to add in terms of how to mitigate or lessen the risk of taking opioids.

Dr. Matthew Philp:

Yeah, I think I would agree with what Dr. Cowan said. And just having mindfulness. I think about medication safety in terms of other people in the household that can have access to these things is an important topic that's often not discussed or talked about... you know, don't hold onto these medications. Don't keep them in your medicine cabinet or lying around where a curious teenager or someone else in the home could come across them. Someone else that may have had an issue with addiction in the past. It can be another source, and it's a common source. I think one of the things we've realized is that traditionally, we overprescribed a lot of medications. And as physicians, we are putting a lot of these medications out in people's homes, and they were being used for other things than their intended use. It's just what happened. So I think that's an important to topic too, to think about, talk about, and understand.

Pamela Braun: Yeah, you raised a really great point. And I think, Dr. Cowan, you included this on your list as well, about making sure that patients know about the need to dispose excess pills. And Dr. Cowan, I don't know if you could talk a little bit about it, is that a conversation that you or someone from your surgical team have with your patients? And when would that be expected to happen, and is there information about how to do that? I'm just curious how that plays out.

Dr. Scott Cowan: Yes. I think that's part of the initial conversation. If you go on the internet and you search up the DEA webpage, you put in your zip code, and you can find out where your nearest takeback site is located. It's convenient and accessible to the patients.

Dr. Matthew Philp: Interestingly, you actually get on the FDA website and they have an approved flush list, too. And most to the narcotics that we would prescribe for postoperative pain are on there. Sometimes taking medications to a dropbox can be tough. Police stations, I think in Philadelphia, take them too, but it's tough for people to get there. And then actually the FDA says that the benefits outweigh the risks of flushing these medications down. So don't keep these extra pain medications around your home.

Pamela Braun: Good point. I meant to ask either one of you, when you're having these conversations with patients or with doctors—I sometimes accompany either a child or a parent, caretaker or family members—do you suggest that patients, when they're meeting with their surgeons, bring along a caretaker, a family member? And what's the purpose? What does that look like in your conversation?

Dr. Scott Cowan: Sure. I think it's incredibly important to engage your family members when possible in the perioperative and the postoperative plan. Discharge instructions, as many of us know, can be incredibly confusing at times. And it's always helpful to have other family members present, particularly at that time of discharge, to be that extra set of ears and be that individual who can support the patient after the time of discharge. So I think the more family involvement and caregiver involvement throughout the whole phase of care, the better.

Dr. Matthew Philp: Yeah, I completely agree. One thing I wanted to mention, I think Pennsylvania and New Jersey, Surgical Opioid Stewardship Group has really done a great job of putting together some very accessible materials for patients that is well written, easy to understand, available in different languages for patients that may not speak English as a first language, and could be a good resource for people to have afterwards. Because sometimes these conversations that you have, you forget some of the details when you're thinking about other surgical complications or other things that are of concern to you as a patient. So having those good quality materials or other good resources online that you can get to is very important.

Pamela Braun: One of the things Dr. Philp, that you included on your list, and I really liked, you said we are not judgmental. And I like that. Can you describe a little bit what you mean by that? And what's your message to patients in that phrase?

Dr. Matthew Philp: In referring to the prior history of opioid or substance abuse, we need to know what a patient's history is. Have you had problems with drug addiction in the past, or alcohol dependence or any other substance use? And we don't want to be judgmental, we just want to help patients come up with the best plan for them. As we mentioned before, talking about planning, it's all about having as much information as possible. The more we know, the better we can plan and have a good outcome. I still think the pendulum swing a little bit too far in terms of avoiding narcotics at all costs, and that can be a problem for people. We don't want to withhold pain medication, and that's not our goal as physicians here. It's really just about being much more thoughtful and precise about how we use these medications. I encourage patients to volunteer this information to their surgeons: I've had issues in the past with drug, alcohol dependence. It's important for us to know.

Dr. Scott Cowan: I echo Dr. Philp's comments, and just telling the patient that the care team is deeply committed to the success of the surgery. I think to let the patient know that all these other modalities are being used to help block the different pathways that pain use to get back and forth within your body, from the site of the surgery, to your brain. And that we use all these medications to help block all the different pathways that pain uses to get through to your brain is very important.

Pamela Braun: I think you both raise a really good point. There's other techniques or strategies. And I think sometimes our patients in particular may not know that there are so many other ways to really effectively ... and can be very effective at managing pain. And I think you both have cited a number of those strategies. Are there any others that maybe we haven't talked about that you know of or that you would suggest for your patients?

Dr. Matthew Philp: I think the preemptive analgesic is a very important part of what I do in my surgical practice, both major and minor surgery. I think it makes a huge difference, getting those medications on board before the patients have incisions that cause the pain stimuli.

Pamela Braun: And I'm thinking, now that your patients had surgery, they've recovered safely and you're sending them home. And now they're home. And I think for some, it's really scary. I don't know if either of you have any advice for patients that once home, how do I know how to taper or wean myself off medications, and how I can be an advocate for my own pain? Do you have any suggestions for patients now that they're home? And maybe I'll start with you, Dr. Cowan.

Dr. Scott Cowan: Again, I think that's a really important conversation to have early, so that psychologically, the patient can think about these things before they're actually in pain and struggling. The other thing is, is that we routinely, on our surgical services, contact our patients early after surgery. Pain is a major focus during that conversation. And frequently that phone call's made by an NP or a PA. And it's very important that the pain is assessed during that conversation, and the patient is given recommendations on how to address it if it's not adequately controlled. If it is controlled without opioid, then that's fantastic. Again, those opioids really do cause a lot of complications, so our goal is to comfortably transition off of them as early as possible. And our NPSs and PAs and our nurses and physicians, they all can help that patient transition off after surgery.

Pamela Braun: Thank you. Dr. Philp, anything to add?

Dr. Matthew Philp: Yeah, I think it's a great question. I always tell people that that the first day is always the worst, or that evening after surgery is always the worst. And every day, usually it gets better. I mean, typically, when we do something surgically, we're correcting a problem. I tell patients that they should be coming off those medications after a couple days, typically. And if not, then we should be having a conversation. There should be a phone call. I think Dr. Cowan mentioned, we do follow patients pretty closely, but it's always okay to call. If your pain's dramatically worsened, you should let us know. It could be a sign of other things going on that we need to know about.

Pamela Braun: Good suggestion. If I'm a patient that, I'm having surgery scheduled, and I decide that I don't think I want an opioid, is that okay? And then the second part to that, if I am recovering and I'm thinking, “oh, I think I do need an opioid. I didn't want to; and I now do.” Is that okay?

Dr. Scott Cowan: Yeah. I think it's, again, important to have that discussion upfront and let the provider know that you really would like to stay away, and not use any opioids if possible. And really there are so many excellent medications now that are being used that fall out of that opioid classification in the hospital, that now we do have those options to offer non-opioid surgery. And there is always the opportunity to add opioids after surgery if pain control is not adequately controlled with these alternative methods. So, would love to have that conversation with patients. There are perhaps some myths or perhaps some misconceptions about opioid use after surgery. And of course, we definitely want patients to take as few as possible for the shortest amount of time as possible. But as Dr. Philp mentioned earlier, there are situations when there is true uncontrolled pain, that it should not be thought of by any means by the patient as a weakness. But it is a way to transition through that first 24, 48, 72 hours, and then stop the opioid intake and then transition over to that around the clock Motrin and Tylenol.

Dr. Matthew Philp: Yeah, totally agree. I certainly see more patients nowadays saying they don't want opioids or narcotics, because I think there is a lot of public awareness about the opioid epidemic. And it's totally okay. You have a plan, but sometimes your plan goes a little sideways and you have to make adjustments. And that's totally fine. And I think patients should know there are different types of opioids. There are some that are not as strong, some in the middle, and some that are more strong, and you can always change doses. So we can go with something like Tramadol, for example. Or even Tylenol number three with some codeine, that's not as strong. There are different options that we have. One of the things I think a lot of research has shown is that surgeons would always overprescribe for various reasons, but one of them being that we worried about patients running out of medications or not having access. And now that we have the availability to do this electronically, it really makes a big difference for the ability to rescue patients that need it.

Pamela Braun: I know, Dr. Cowan, that's something you've described to us as well in some of our collaborative calls. I don't know if you want to elaborate on that as well.

Dr. Scott Cowan: Yeah. I think Dr. Philp gave a nice overview. The only thing I would add would be, it's important that the conversations in terms of pain, or ongoing pain, really are routed through either the surgeon or the surgeon's direct staff. At times, these requests go to the resident trainees, and renewals can happen that way. And unfortunately, it's really important that the surgeon or the direct provider is involved in those conversations

Pamela Braun: I wonder if either of you have had any difficult conversations with patients about opioids or pain management? Either patients who were really insisting on something, or struggled with some of the information you were provided. Can you think of any instances where it was a really tough conversation, and what did you do?

Dr. Matthew Philp: Yeah, I think we've all had challenging conversations at times. I think the biggest challenge that we have sometimes are patients that continue to request pain medications for extended period after surgery. especially when we do major procedures, major abdominal surgery or thoracic surgery. We always expect that there's going to be some cases where patients may need opioids for longer periods of times. The challenging situations come when patients are sometimes maybe, two, three, four months after surgery, healing is taking place, but they're still having pain. And those are the conversations I think that are the most challenging. And sometimes you have to ask questions that are uncomfortable. You have to ask the patient what is the pain? Is there other things going on in their life? What's really driving the request? Because most of the time, it's not from the surgery, there's other reasons. And they can be uncomfortable to ask, I'll be honest. Even as a physician, it can be uncomfortable to ask people about dependence and diversion.

Pamela Braun: Yeah. I would imagine that'd be really tough. You have the patient's safety, their recovery in mind and want to provide them with good advice.

Dr. Scott Cowan: Yeah. Those conversations are occurring a little less commonly, given the transition to minimally invasive approaches. Not that they're not happening now, but the good news is, as opposed to what used to be a very large incision in the chest or in the abdomen, or in different places in the body, has now transitioned sometimes to either needle size incisions in vascular procedures or small ports in many other surgeries. So, the trauma that is inflicted during these surgeries is a lot less. So hopefully that will continue to evolve, and with a result in decrease in the need for postoperative opioids.

Pamela Braun: If you had to suggest to patients, what two questions that you wish they would ask you before surgery, what would be some of those questions you want them to ask you?

Dr. Matthew Philp: Only two questions?

Pamela Braun: Or you can do more.

Dr. Scott Cowan: The one question would be, what can I do to decrease my risk of having complications or problems after surgery? And we give patients a lot of instructions before surgery, in terms of quitting smoking and not using illicit drugs, and really remaining active after surgery. But you also can tie in that conversation about opioid use and letting them know that even after surgery, you can do things to decrease your risk of complications. And one of those is minimizing the use of opioids, both in hospital, in the postoperative period, as well as when they go home. Because they'll, in all likelihood, recover quicker and get back to their normal function.

Dr. Matthew Philp: I do GI surgery, mostly. And I think one of the things that ... addiction is always a concern, right? Whenever we're talking about opioid use. But I think that happens, thankfully, fairly rarely. But anybody that's taken an opioid before gets constipated, can frequently get nauseated. And it's probably actually one of the biggest drivers of increasing recovery time for my patients that are having GI surgery. Physicians call it ileus, but basically it's bloating, it's nausea, it's vomiting. If you've ever taken an opiate before, it's the constipation that comes afterwards and the issues that result from that. And I think understanding those things and minimizing the amounts, taking laxatives to help counteract some of those, the slowing effect that the narcotics have on the GI tract can be very important, and help people recover faster. So asking about some of those ... what are the other potential side effects? Obviously, addiction is of huge concern and it's very important, what we're talking about a lot today. But there's a lot of other things that can still happen, and you can mitigate some of those problems ... from happening.

Pamela Braun: Some of the changes over time when it comes to pain control, opioid use, recovery, surgery, incisions. What other maybe changes or trends related to patient attitudes toward pain or opioids have you seen over your years of practice? Any other changes that maybe you haven't addressed that you'd like to cite?

Dr. Matthew Philp: I think there's a lot more awareness. Patients know these medications now; they understand them a little bit better. I think people are just more aware. I mean, I think the media's certainly done a good job of, talking about the opioid epidemic. It's certainly been in the mainstream news for a long time now, the last couple years. I think that's probably the biggest thing, is awareness for patients and understanding what these medications are, how to use them. I think that's the biggest thing that I noticed.

Dr. Scott Cowan: Yeah, I think there's going to be some big advances that are coming down the pipeline in the future that will impact opioid use. There's a group at the BI up in Boston who are using an AI platform to predict and better estimate the need for opioids and opioid use after discharge. I think technology is going to help make decisions about the number of MMEs and the needs, based upon data that is in the medical record and the patient's history. So, I think that'll be exciting. And there's also, I think, the opportunity to explore new types of pain medicines that are not as addictive as opioids.

Pamela Braun: As we conclude todays’ podcast, I would like to take a minute to provide a high level summary of our discussion. The top things you want your patients to know about opioids and pain management when they need to have surgery are:

1. Some pain after surgery is normal and expected.
2. It’s important to have a conversation with your surgeon ab out pain management both before surgery and after surgery.
3. Opioids can be used safely after surgery.
4. There are many other ways to effectively manage pain without opioids.
5. It’s important to properly dispose of excess pills, both opioids and non-opioids.