When Surgeons Clamp Down on Opioids After Cardiac Operations

SAN DIEGO — Given the long- and short-term harms of opioids, cardiac surgeons stressed that it is feasible to put strict limits around perioperative opioid use without giving up pain control and patient satisfaction.

Approximately one-third of patients do not need opioids on discharge after cardiac surgery, according to Kathleen Clement, MD, of Tripler Army Medical Center in Honolulu, in a discussion at the Society of Thoracic Surgeons (STS) annual meeting.

Standardization of opioid prescribing can reduce the excessive perioperative opioid use that is a major modifiable risk factor of new persistent opioid use after heart surgery, she said, citing work from the Michigan group that created prescribing recommendations for postdischarge opioids (e.g., around-the-clock acetaminophen). This experience effectively reduced opioid prescribing by 40% and brought postdischarge opioids from a median three to zero pills. Importantly, there was no increase in opioid refills or increase in patient-reported pain levels the first week after surgery.

Nevertheless, persistent postoperative pain remains a challenge as it affects nearly 20% of patients at 2 years after cardiac surgery, Clement acknowledged.

Caution is also warranted when having patients go the route of non-opioid alternatives. “This is not a panacea. You can’t provide these indiscriminately,” said Michael Grant, MD, MSE, of Johns Hopkins University School of Medicine in Baltimore, at the session.

He noted that the evidence is limited for non-opioids in cardiac surgery relative to other settings. Potential cardiac side effects include tachycardia with ketamine, hypotension and bradycardia with dexmedetomidine, and arrhythmia with lidocaine.

Even so, he and his colleagues have been able to bring intraoperative fentanyl down from the historical 1,000 μg per case to now less than 150 μg, which has been stable in the last 2 to 3 years, Grant said.

Meanwhile, remifentanil has been nixed altogether from their practice, he said, because of the problem of opioid-induced hyperalgesia — the phenomenon that has opioid recipients growing their tolerance to opioids and requiring escalating doses subsequently.

Opioid-sparing, multimodal pain management is an important principle of Enhanced Recovery After Cardiac Surgery (ERAS). Non-pharmaceutical approaches to pain management include ice, relaxation techniques, music therapy, physiotherapy, and acupuncture.

Marc Gerdisch, MD, of Franciscan Health Heart Center in Indianapolis, said that total narcotic usage has fallen by over 90% at his institution since implementing an ERAS protocol plus rigid sternal fixation. Over half of patients now receive zero narcotics, and sternotomy pain scores have even improved modestly.

Another plus is that patients are much more mobile and more likely to be discharged home instead of an extended care facility nowadays, Gerdisch said. “This means something to people, that they’re not disabled.”

According to CDC data, opioids were involved in over 80% of drug overdose deaths in the U.S. in 2021. Overdose deaths continue their upward march and have accelerated during the pandemic.

Earlier this month, by eliminating the X waiver requirement for medication-assisted treatment, the Biden administration made it more accessible for healthcare professionals to offer buprenorphine (Suboxone) for opioid use disorder.