Less is more for teen pain relief

One of my most treasured “assets” is a video of one of my teenage patients doing some beautiful gymnastic backflips after recovering from scoliosis surgery. Her grace and flexibility do more than remind me of a successful patient experience – they remind me of the power of challenging the “standard” approach.

After decades of surgeons managing the postoperative pain of patients with highly addictive opioids, the opioid crisis in the United States is forcing providers to rethink this strategy, especially as we learn that nearly half of opioid prescriptions pediatrics are high risk. It can also affect teens as they become adults: in a sample of nearly 27,000 teens followed through adulthood, 45.7% reported prescription drug abuse at least once during their the 32-year study period. Of those who reported PDM, 40% reported poly-PDM (abuse of more than one class of prescription drugs during the same time period).

It is a priority in scoliosis surgery.

Scoliosis occurs when the curvature of the spine is 10 degrees or more. My patients, however, can endure dramatic, organ-crushing bends – 76 degrees, for example, and sometimes over 100 degrees.

The procedure to correct it is complex, exposing the entire spine, tearing 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 was common to allow patients to manage their postoperative pain via patient-controlled analgesia (PCA), painkillers at the push of a button. Patients would use PCA for a few days in the hospital, receive oral and/or IV painkillers, and go home with a prescription for 2 or 3 weeks of medication.

Finally, we were confronted with difficult facts: 10 to 15% of patients operated on for scoliosis have prolonged use of opioids. And, if it happens before high school, our patients had a 30% chance of becoming addicted to opioids as adults. We also couldn’t ignore that hospitalization times and post-surgery prescriptions did not take into account the time it took to develop an addiction – only 5 days.

It was time to assess whether patients could feel comfortable with less medication. It was a sensitive proposition given the age of our patients and the complexity of the procedure. But if reconsidering our pain relief strategy meant keeping children who were spinning back from the clutches of addiction, then it was our duty to try.

The questioning of our methods worked. We were able to reduce the opioids we give to these children by 80% – and we have been using this protocol successfully for 3 years. Others are starting to explore that too.

Now, anesthesiologists administer micro-doses of painkillers directly to the spine, similar to an epidural. We give patients about 3 days of painkillers while they are in the hospital, followed by over-the-counter acetaminophen. PCAs are gone.

We know it works because of what we don’t see: itchiness, constipation and depression. We remove the catheters earlier. Our adolescent patients are more alert and cooperative. They participate in their own care. More importantly, approximately 90% of our patients are home within 3-4 days. When using PCA, hospital stays were 5-7 days.

The families supported us as we explained our approach to pain management before surgery. They too want to prevent the risk of future child dependency.

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

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

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