Opinion | Less Is More in Providing Pain Relief to Teens

One of my most prized “possessions” is a video of one of my teen patients doing gorgeous gymnastic backflips following her recovery from scoliosis surgery. Her grace and flexibility do more than remind me of a successful patient experience — they remind me of the power of questioning the “standard” approach.

After decades of surgeons managing patients’ post-operative pain with highly addictive opioids, the U.S. opioid crisis is forcing providers to rethink that strategy, especially as we learn that almost half of pediatric opioid prescriptions are high risk. This also can affect teens as they become adults: In a sample of nearly 27,000 teens followed throughout adulthood, 45.7% reported past-year prescription drug misuse (PDM) at least once during the 32-year study period. Among those who reported PDM, 40% reported poly-PDM (misuse of more than one prescription drug class in the same time period).

It’s top-of-mind in scoliosis surgery.

Scoliosis occurs when the curve of the spine is 10 degrees or more. My patients, however, can endure dramatic, organ-crushing curvatures — 76 degrees, for example, and sometimes more than 100 degrees.

The procedure to correct it is complex, exposing the entire spine, ripping apart muscles and inserting rods and screws. Sometimes I cut four or five ribs to make my young patients’ chests look “normal.” Imagine the post-surgical pain.

It had been common to allow patients to manage their post-operative pain via patient-controlled analgesia (PCA), pain medication at the touch of a button. Patients would use the PCA for a few days in the hospital, receive oral and/or IV pain medication and go home with a prescription for 2 or 3 weeks of medication.

Eventually though, we were confronted with difficult facts: 10 to 15% of patients undergoing scoliosis surgery experience prolonged opioid use. And, if this occurs before high school, our patients faced a 30% chance of becoming dependent on opioids as adults. We also couldn’t ignore that hospitalization times and post-surgical prescriptions weren’t mindful of how long it takes to develop an addiction — just 5 days.

It was time to assess whether patients could be comfortable with less medication. It was a sensitive proposition given our patients’ ages and the complex nature of the procedure. But if reconsidering our pain-relief strategy meant keeping back-flipping kids from the clutches of addiction, then it was our obligation to try.

Questioning our methods worked. We’ve been able to reduce the opioids we give these kids by 80% — and we’ve now been using this protocol successfully for 3 years. Others are beginning to explore this too.

Now anesthesiologists are administering micro-doses of pain medication directly to the spine, epidural-style. We’re giving patients about 3 days of pain medication while they’re in the hospital, followed by over-the-counter acetaminophen. The PCAs are gone.

We know it’s working because of what we’re not seeing: itching, constipation, and depression. We’re removing catheters sooner. Our teen patients are more alert and cooperative. They’re participating in their own care. Most importantly, about 90% of our patients are home in 3 or 4 days. When they used a PCA, hospital stays were 5 to 7 days.

Families have been supportive as we explain our pain management approach before surgery. They too want to prevent kids’ risk for future addiction.

It can be difficult to question a longstanding strategy, especially one involving young patients who face a complex procedure, followed by a potentially painful recovery. It took cooperation and thoughtful execution among surgical staff and anesthesiologists, and clear communication with our patients and their families. But if the approach makes a dent in opioid dependence — and inspires a few backflips — the effort is worthwhile.

Vishal Sarwahi, MD, is director of Northwell Health’s Center for Minimally Invasive Scoliosis Surgery and the Center for Advanced Pediatric Orthopedics at Cohen Children’s Medical Center.