Women far outpace men in their use of opioids. Surgery is one gateway to dependence.

Nine in 10 patients receive opioids to manage post-surgical pain

(iStock/Lily illustration)

After slipping and falling, Dawn Kitz’s shoulder hurt so badly, she could barely hold her grandson. An MRI revealed the source of her pain: Kitz had two rotator cuff tears, one full and one partial. She needed surgery.

Kitz, a 58-year-old special education teacher from Rockland County, N.Y., started to do her research. She knew a couple of people who had undergone rotator cuff repairs, and heard comments like, “I’d rather give birth 10 times than do that again.” Kitz joined a Facebook group where people shared their experiences.

“Most of the experiences I read about were pretty horrific,” Kitz said. “So I went into it very anxious about the pain afterward.”

But the surgery was easier than she anticipated. Kitz underwent an arthroscopic rotator cuff repair on Wednesday. She was back to work by Monday.

Her surgeon, Dr. Paul Sethi, prescribed a small number of painkillers, but Kitz didn’t take them all. She switched to Tylenol after about a day and a half.

Now, her grandson is almost a year old, and holding him is “a breeze,” Kitz said. And those opioids she never took? They’re still in her medicine cabinet.

Nine in 10 patients receive opioids to manage post-surgical pain, according to “United States for Non-Dependence,” an analysis conducted by the QuintilesIMS Institute and sponsored by Pacira Pharmaceuticals, Inc.

This puts women, who are prescribed more opioids than men, at a higher risk for dependence and addiction.

The analysis examined seven inpatient and outpatient surgical procedures, including hernia, total knee replacement, colectomy, hysterectomy, total hip replacement, sleeve gastrectomy and rotator cuff surgery.

Excluding hysterectomies, researchers found that women were 40 percent more likely than men to become persistent opioid users after these procedures.

The analysis also revealed that:

  • Middle age women consume the most opioids. Women ages 40 to 59 receive twice as many opioid prescriptions as their male counterparts. More women from this age group die from opioids.
  • Gen X women who underwent knee replacement surgery had the highest rate of persistent opioid use following their procedure.
  • Women could be more prone to opioid dependence because of differences in body fat, metabolism and hormones.

Kitz never became addicted to opioids. Since 1997, she has undergone several major procedures, including a hysterectomy, foot surgeries and biopsies.

“I’ve always been prescribed something for the pain for after the surgery,” Kitz said. “Unless I really feel that I need it, I try not to take it because it does make me feel sick.”

Like Kitz, many patients don’t take all their pills. Unused opioids remain at the bottom of purses and backpacks, in bathroom cabinets and glove compartments.

Rural areas are also more vulnerable to the opioid epidemic. One reason? Some medical facilities are far away, meaning doctors might write larger prescriptions for patients, leading to higher number of unused pills.

The FDA recommends disposing of most opioids by flushing them down the sink or toilet, depending on the type of medication. If there aren’t extra pills floating around, people are less likely to misuse them. They are also less likely to get into the hands of family or friends who were never prescribed the medication.

Sethi, Kitz’s doctor, recognizes that medical professionals have contributed to the opioid epidemic. According to the QuintilesIMS Institute analysis, patients given opioid prescriptions for post-surgical pain received an average of 85 pills in 2016.

At least 17 states have enacted rules to lessen the number of painkillers doctors can prescribe. Some states have passed laws limiting the duration of initial opioid prescriptions to five or seven days. Over the summer, a law in Kentucky went into effect, putting a three-day limit on painkiller prescriptions for acute pain. And last week, CVS announced its pharmacies would limit opioid prescriptions to seven days for certain conditions beginning Feb. 1.

Within the past few years, as Sethi and his colleagues began to research the effects of excess opioids, they started to reduce the number of pills they prescribe each patient. After a shoulder surgery, a patient might get a prescription for 10 to 12 pills, whereas other surgeons might give between 60 and 80. He also discourages patients from asking for a refill.

“We have to be more responsible as doctors,” Sethi said. “I think there’s a disconnect between what really should be happening … and what we actually practice.”

Sethi has also been using a method called multimodal anesthesia in the operating room to reduce the amount of pain a patient feels post-surgery. It’s not a new concept, Sethi said, but surgeons and anesthesiologists are exploring ways to administer non-narcotic medications during procedures to help ease postoperative pain.

Think of reducing pain like putting out a fire, Sethi said. Dousing it with water isn’t the most effective way. You have to find the source and extinguish smaller fires along the way.

The QuintilesIMS Institute analysis revealed that one in 10 patients who had not been taking opioids prior to their surgery continued to use the drugs for three to six months after their procedure.

Sethi considers opioid dependence to be a surgical risk, and it’s something he discusses with his patients. Patients should feel empowered to ask their doctors about pain management, he said:

  • How will you help manage my pain?
  • Why will I have this pain and how long is it expected to last?
  • Please discuss with me what strategies you’re using to manage my pain within the operating room and after the operating room.