opioids-before-surgery-06182019_FINAL.pdfPrior to Surgery
Prior to Surgery
Pain management begins with optimizing our ability to manage pain post operatively. Unfortunately, this frequently includes a discussion about chronic narcotic use.
Pain management begins with optimizing our ability to manage pain post operatively. Unfortunately, this frequently includes a discussion about chronic narcotic use.
Narcotic habituation is a national epidemic. No other country in the world permits the extended use of outpatient narcotic pharmaceuticals. We are just beginning to address the political, financial, and medical issues contributing to the problem.
Narcotic habituation is a national epidemic. No other country in the world permits the extended use of outpatient narcotic pharmaceuticals. We are just beginning to address the political, financial, and medical issues contributing to the problem.
Cessation from narcotics is paramount. Daily narcotic use will progressively increase sensitivity to pain and can become a permanent change. The nerves express increasing numbers of opioid receptors with chronic narcotic exposure. When the narcotics go away, the unsatisfied receptors will cause the nerve to send pain signals regardless of a painful stimulus or not.
Cessation from narcotics is paramount. Daily narcotic use will progressively increase sensitivity to pain and can become a permanent change. The nerves express increasing numbers of opioid receptors with chronic narcotic exposure. When the narcotics go away, the unsatisfied receptors will cause the nerve to send pain signals regardless of a painful stimulus or not.
We require narcotic cessation prior to surgical intervention. This is the universally agreed upon position of the American Association of Hip and Knee Surgeons. Please read the statement publication in the HERE. It may seem counter-intuitive, but the high levels of narcotics required post-operatively in attempt to control pain in a person who is habituated can dangerously suppress the breathing respiratory drive. In addition, pain is nearly impossible to control in many habituated patients. If you take narcotics, you should work with your prescriber to begin a cessation program, or just stop taking them gradually. It is ultimately up to you to stop.
We require narcotic cessation prior to surgical intervention. This is the universally agreed upon position of the American Association of Hip and Knee Surgeons. Please read the statement publication in the HERE. It may seem counter-intuitive, but the high levels of narcotics required post-operatively in attempt to control pain in a person who is habituated can dangerously suppress the breathing respiratory drive. In addition, pain is nearly impossible to control in many habituated patients. If you take narcotics, you should work with your prescriber to begin a cessation program, or just stop taking them gradually. It is ultimately up to you to stop.
Perioperative
Perioperative
Preoperative:
Preoperative:
You will be given both oral and intravenous medications as part of a multimodal preemptive pain management protocol.
You will be given both oral and intravenous medications as part of a multimodal preemptive pain management protocol.
Anesthesia:
Anesthesia:
When appropriate we utilize either a spinal blockade (injection of medication into the spinal canal which temporarily blocks nerve function below the waist) or a general anesthetic (chemical sedation and paralysis through intravenous medication requiring breathing assistance). You are not awake with a spinal blockade and will not remember any significant portion of your surgery.
When appropriate we utilize either a spinal blockade (injection of medication into the spinal canal which temporarily blocks nerve function below the waist) or a general anesthetic (chemical sedation and paralysis through intravenous medication requiring breathing assistance). You are not awake with a spinal blockade and will not remember any significant portion of your surgery.
The choice is ultimately made by you and your anesthesiologist. I have no preference for most patients and both are safe and effective.
The choice is ultimately made by you and your anesthesiologist. I have no preference for most patients and both are safe and effective.
In addition, most anesthesiologists will offer a regional block (injection into a nerve region outside of the spine) locally into the region of the nerves going to the hip. This provides extended pain relief benefit for 12-24 hours after the surgery is complete.
In addition, most anesthesiologists will offer a regional block (injection into a nerve region outside of the spine) locally into the region of the nerves going to the hip. This provides extended pain relief benefit for 12-24 hours after the surgery is complete.
Intraoperative:
Intraoperative:
During surgery, the entire surgical field is infiltrated with a multi-agent solution of narcotic, anti-inflammatory, and local anesthetic into the tissues surrounding the surgical site.
During surgery, the entire surgical field is infiltrated with a multi-agent solution of narcotic, anti-inflammatory, and local anesthetic into the tissues surrounding the surgical site.
Medication
Medication
The primary medical therapy for pain is oral anti-inflammatory medications.
The primary medical therapy for pain is oral anti-inflammatory medications.
Tylenol/Acetaminophen 1000mg (two 500 mg tablets) every 8 hours
Tylenol/Acetaminophen 1000mg (two 500 mg tablets) every 8 hours
Celebrex/Celecoxib 200mg every 12 hours
Celebrex/Celecoxib 200mg every 12 hours
These should be taken on a scheduled basis (whether you have pain or not) for the first 1-2 weeks after surgery.
These should be taken on a scheduled basis (whether you have pain or not) for the first 1-2 weeks after surgery.
If your pain has subsided earlier, you may discontinue scheduled use and take only as needed.
If your pain has subsided earlier, you may discontinue scheduled use and take only as needed.
They may be alternated or taken together. They do not interact.
They may be alternated or taken together. They do not interact.
There are alternatives that may be used based on patient preference.
There are alternatives that may be used based on patient preference.
Oxycodone or Tramadol will also be prescribed. These are oral narcotics.
Oxycodone or Tramadol will also be prescribed. These are oral narcotics.
Narcotics are for short term treatment of surgical/acute pain when other methods are insufficient.
Narcotics are for short term treatment of surgical/acute pain when other methods are insufficient.
They can be dangerous. They are addictive and will lead to withdrawal symptoms within 2-3 days of use.
They can be dangerous. They are addictive and will lead to withdrawal symptoms within 2-3 days of use.
Beyond the initial prescription, we do not prescribe additional narcotics, and this is rarely requested or needed.
Beyond the initial prescription, we do not prescribe additional narcotics, and this is rarely requested or needed.
Your goal should be to no longer use narcotics after 3 days from the date of surgery.
Your goal should be to no longer use narcotics after 3 days from the date of surgery.
Cryotherapy
Cryotherapy
Placing a gel pack under your compressive pants or even a simple plastic bag of ice wrapped in a pillow case or towel over the hip can be very helpful.
Placing a gel pack under your compressive pants or even a simple plastic bag of ice wrapped in a pillow case or towel over the hip can be very helpful.
Gel Packs are available in many stores or on the internet.
Gel Packs are available in many stores or on the internet.
A supply of at least 2 is recommended for alternating packs.
A supply of at least 2 is recommended for alternating packs.
Activity
Activity
If you feel your pain is increasing, you may need to decrease your activity.
If you feel your pain is increasing, you may need to decrease your activity.
Increased tissue movement will increase inflammation, swelling, and fluid production.
Increased tissue movement will increase inflammation, swelling, and fluid production.
Patients commonly feel so good at not having the pain of arthritis, that they may wish to engage in the activities they have not been able to do. This is ok, but it may come with some discomfort.
Patients commonly feel so good at not having the pain of arthritis, that they may wish to engage in the activities they have not been able to do. This is ok, but it may come with some discomfort.
You do not need to "push" yourself after surgery. Your strength and motion will return as your tissue heals.
You do not need to "push" yourself after surgery. Your strength and motion will return as your tissue heals.
Increased early activity can cause more inflammation and pain.
Increased early activity can cause more inflammation and pain.
Compression
Compression
Wearing compression pants with or without compression socks can be very helpful.
Wearing compression pants with or without compression socks can be very helpful.
We recommend obtaining two pairs of waist-to-ankle compression pants prior to surgery.
We recommend obtaining two pairs of waist-to-ankle compression pants prior to surgery.
They can be worn together one over the other to increase compression.
They can be worn together one over the other to increase compression.
This is usually only needed for a week or two.
This is usually only needed for a week or two.
They are available at any athletic store or online.
They are available at any athletic store or online.
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