Matthias Behrends, MD: Reducing Post-Operative Pain

Opioids are likely still needed in most cases following trauma or surgery.

While there are concerns over abuse and addiction, opioids did have medicinal value in relieving pain, particularly for intense acute pain following trauma or surgery.

But balancing the value of the treatment class with the concerns for long-term abuse.

While there are alternatives that can be used, there still are many situations where opioids are the best and sometimes only treatment option to alleviate pain.

But there is a way to leverage the value of opioids, while reducing the likelihood of abuse or addiction by targeting specific, short-term situations where opioids could be used post-operation.

In an interview with HCPLive®, Matthias Behrends, MD, Associate Clinical Professor and Director, Acute Pain Service, University of California San Francisco, explained how prescribers are beginning to better understand when it is and isn’t appropriate to prescribe opioid treatments.

Behrends will present during the Evolving Approaches in Pain Management conference in San Diego on August 14 on alternative therapies for post-operative pain.

HCPLive: How important is it for the industry to decide when it is appropriate to treat with opioids and when it might not be appropriate?

Behrends: I would say, at this point, the use of opiates is probably still without alternative when we're talking about the treatment of really painful conditions. And I think the majority, especially with larger surgical procedures fall into that category.

We've been making, I think, tremendous progress in helping to achieve a reduction of opioid use after surgery, especially in the inpatient setting, by using alternatives to opiates. It's probably not a realistic goal that we will be able to achieve opiate avoidance in the majority have cases, especially after a major surgery.

I think our goal should really be trying to achieve opiate avoidance, trying to reduce the number of opiates we're using. The most important part, I think, is reducing the time we depend on opiates for pain management.

Unless we're getting a new class of drugs that is similarly potent as opiates, it's probably not realistic to assume that we'll be able to manage without opiates anytime soon.

HCPLive: Is it fair to say opioids have more of a use in acute pain and shouldn’t be prescribed as much to treat chronic pain conditions?

Behrends: I think it's fair to say that opiates should not be the treatment of choice for chronic non cancer pain. This is something where we have probably more angles with non-opiates, alternatives, but also behavioral therapy to deal with chronic pain. I'm not saying that some chronic pain patients do not need opiates.

But I think we should be focused on reducing the long term use of opiates and I think this is also where most of the dangers around opiate use is being located.

Cancer pain is an interesting topic because cancer pain has always been kind of like taken out of these efforts to limit opioid use in chronic pain.

But a lot of cancers are curable nowadays. And I think we have to have a discussion about whether it's really appropriate to be very permissive with opioid use and cancer pain, especially those cases where patients have a good chance of cancer remission.

And acute pain is a little bit different because it's probably more dynamic field in terms of that we're very often deal with very severe pain that in most cases, improves in a reasonably short time.

So most patients would recover from pain. But pain can be really intense right after surgery or right after trauma.

So it is appropriate to use a drug that has actually a pretty good safety profile for short term use, especially if it's been administered in a more controlled environment as a hospital.

And although adverse events do happen with opioid use, I think the need for potent analgesic options still makes it necessary to use opiates.

I think it's appropriate to use opiates for severe acute pain, we just have to focus on making sure that these opiates will be tapered down as acute pain improves.

And we have to ensure that we take care of that patients at the end, basically successfully get off these opiates. Now the concept of transitional care is probably something that we've been neglecting so far. I think it's our responsibility to ensure that patients at some point stop taking these opiates.

HCPLive: What are some of promising alternatives to opioids that should be considered options?

Behrends: There’s probably nothing that rivals the potency, the pain control you can achieve with opiates. Everybody is raving about multimodal analgesia and adjuncts to opiates but there's only so much we can achieve.

For example, with the use of Tylenol or gabapentin, not everybody can take all these drugs so they are normally at the core of any multimodal regimen.

The only thing that really comparisons probably even potentially ther than opiates are regional anesthesia techniques, especially with an emphasis on continuous techniques, especially with an emphasis on continuous techniques.

Any effort that promotes a more aggressive use of regional anesthesia, the more aggressive use of continuous techniques for example, sending patients home with a disposable water pump that they can send back and using a catheter technique for an extended period of time is probably the best thing we can offer patients.

Other modalities such as intravenous lidocaine, intravenous ketamine are mostly limited to the inpatient setting and are really more adjuncts.

HCPLive: What are some of the important factors doctors must weight as they decide on whether to prescribe post-operative opioids?

Behrends: If there's an alternative to an opiate, you should always consider using alternatives. Again, what I've been trying to emphasize is, sometimes pain is so severe that we feel that we don't have an alternative to an opiate, if there are alternatives available and it's an alternative that may not be associated with side effects that are equally undesirable.

As you know, there's been, for example, huge discussions about the appropriateness of the use of gabapentinoids perioperatively. So that's discussion in itself, that kind of complicates a little bit. But if we have an alternative approach to treat pain that's reasonably safe, then it's very reasonable to avoid opiates.

HCPLive: Do you think we are ultimately heading in the right direction in terms of reducing dependency for some addictive substances while also appropriately treating pain?

Behrends: The opioid epidemic is a challenging topic, there's been a lot of focus on the contribution, for example of pain management providers on the opioid epidemic. And that is appropriate because, yeah, we're prescribing very often drugs, and we're responsible for some patients getting on these drugs.

But the opiate epidemic has a lot more reasons than pain providers, writing for opiates for pain management, and we have to see it in that context.

We're talking about the social components, why patients are taking opiates, the lack of treatment options, the lack of mental health treatment options, and so on. So it's a little bit more complex than that.

And I'm not really sure that if a strategy that focused predominantly on the prescriber side for pain management will have a significant impact on addressing the opioid epidemic, because it's just one out of several factors.

We have our share of responsibility there. And the things that we can do and we have to focus on is again, reducing the number of opiates we use in the treatment of chronic non cancer pain.

And the second thing we can do and should do have to do really is making sure that when we use opiates for acute pain, that we help patients and ensure patients to taper off these opiates and discontinue their use, assuming that their pain does not become chronic, even if the pain becomes chronic.

Yeah, we You have to help them using other modalities than opioids to treat chronic pain.