Here's something that curbs opioid use: Pre-surgical counseling

Eric Williams was already leery of opioids before the man who would repair his broken wrist began talking about pain pills.

Asif Ilyas, a Rothman Institute surgeon, told Williams, a 24-year-old from Northeast Philadelphia, that he would write a prescription for only 10 pills.  That number, he said, was based on studies of what most patients use.  He urged Williams to try over-the-counter medicines such as Advil  before resorting to the more powerful — and powerfully addictive — opioids.

Then he handed Williams a computer tablet and asked him to watch a five-minute video that Ilyas had made.  It said that opioids are good painkillers but have some drawbacks: They cause nausea, constipation, and itchiness, and they are addictive.  Patients should try other drugs and ice first. Most won't need opioids for more than two or three days.  Ilyas will not prescribe then long term.  And, he pointed out, the United States accounts for 5 percent of the world's population, but consumes 80 percent of the world's opioid production.  Opioid overdose is the leading cause of accidental death in young people.

Williams watched attentively.  He was not particularly worried about becoming addicted, but did not want to take chances.  He would stick with his plan to "try to bear with the pain" and take other medicines.

That video is part of Ilyas' effort to make sure his patients use the bare minimum amount of opioids. Like many orthopedic surgeons, Ilyas, who specializes in wrist and hand repair,  is grappling with the role his profession might play in fostering opioid abuse.

"Orthopedic surgery is notorious for being one of the surgical fields that have higher levels of post-surgical pain, in general, and orthopedic surgeons are among the highest prescribers of opioids," Ilyas said.

Patients need strong pain medication after bone and joint surgery.  "We can't do what we do without them, frankly," Ilyas said.

Prescribing too many pills, though, increases the odds that patients will develop an addiction or that leftover pills will end up with other family members. A Rothman study in 2016 found that patients who underwent upper-extremity surgery typically used only about a third of the opioid pills their doctors prescribed, about eight of 24.  That's why Williams received only 10 pills to start and was told he could have more if he needed them. 

Ilyas has also found that talking to patients about their medicine is surprisingly effective at reducing opioid use.  He conducted a pilot study of patients who had undergone carpal tunnel release surgery.  Twenty patients were given the kind of pre-surgery information that Williams received.  (Ilyas said patients remember very little of what they are told after surgery.) Another 20 were not counseled.  Patients who received the education used an average of 1.4 pills during their recovery.  Those who did not used 4.2.

Ilyas said the Rothman Institute plans a much larger education study this summer that will include all orthopedic outpatient surgery.  

In the meantime, Ilyas started showing all his patients the video about a year ago.  He estimates that has reduced opioid use by a third to a half.

While many patients, such as Williams, are already concerned about opioids, Ilyas says taking the time to talk about the drugs and expectations makes patients more careful about how much they take. 

"When you're deliberate about it," he said, "they're deliberate about it."

Two patients who had surgery the same day as Williams, Matt Hurray, a 33-year-old teacher from West Chester, and Charlie Cook, 68, a retired electrician from Yardley, took no opioids after their procedures.  Cook said he did not have a lot of pain,  Hurray was uncomfortable but decided to tough it out.  He had taken several Percocets after his injury and did not like them.  Ilyas's video further persuaded him to "bear with it" as much as possible.

Williams said that his wrist hurt for a few weeks, but that he took only the opioids that Ilyas initially prescribed.  After that, as he had planned, he just suffered with the pain.   

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