Jason Zeeman went to his hernia surgery in November ready to run the opioid gauntlet.
His addiction support group had helped him get together a checklist of medical staff who would need to be alerted to his 28-year struggle with painkillers, and helped him rehearse the moments before and after surgery when he’d be most vulnerable to relapse.
But instead of facing a feared parade of pill-pushers, Zeeman learned he was a candidate for Intermountain Healthcare’s new opioid-free surgery option. Instead of fentanyl or hydromorphone, doctors would use a nerve block during the operation, and a few non-opioid painkillers in recovery before turning to ibuprofen and Tylenol.
The combination of alternatives was enough pain relief for Zeeman — and for most of the 250 patients who have opted into the new pain-management protocols for surgery, said Intermountain surgeon Nathan Richards.
"I'm very happy to have an option for other people like me who want to do it without an addiction coming on," Zeeman said.
The new surgery option ties into Intermountain’s ongoing push to lower the number of opioid pills prescribed, with doctors trying to reset their own habits and their patients’ expectations.
For instance, Richards said, patients previously received about 30 opioid tablets following gall bladder removal. But patient surveys showed they only used, on average, five to seven of those pills.
Doctors and nurses have “reflexively” turned to opioids, agreed Will Shakespeare, Intermountain’s director of anesthesiology. He recalled a teenager who had undergone a lengthy operation before he woke up and said, “Ouch” — which prompted a nurse to retrieve painkillers for him.
On further inquiry, the boy explained he said “ouch” only because his arms were stiff from being stationary for so long, Shakespeare said. “We don’t want to have that reflex to go to opioids for any discomfort,” Shakespeare said.
Zeeman said his own addiction began more than 20 years ago, when he was prescribed 120 pills a week for a back injury.
But Intermountain's opioid-free option goes beyond simply reining in overprescriptions in recovery. Perhaps more significantly, surgeons are offering alternatives during surgery itself. Alpha(2) agonists, gabapentinoids, lidocaine and magnesium supplements can change how the nervous system handles pain.
In some studies, opioid use during surgery has been shown to increase pain sensitivity after surgery, Shakespeare said.
But the alternatives can be laborious and some treatment combinations have been pioneered in just the last couple of years. Intermountain has been "pouring a lot infrastructure" into the new protocols, especially in training surgical teams to administer the drugs, Shakespeare said.
"The downsides are time and convenience," Shakespeare said.
Of about 250 patients who have undergone opioid-free surgeries, nearly 90 percent reported adequate pain relief, Shakespeare and Richards said.
But Intermountain is focusing on "patients who are motivated" to sidestep opioids in their surgical care, rather than pressuring patients not to use opioids that could help them.
“There’s never a message saying, ‘Withhold opioids,’” Shakespeare said. “If you need an opioid, it’ll be available.”