NEWS ALERT: NARCOTICS DO NOT TREAT MOST POSTOPERATIVE PAIN.
As in the case with hernia repair, the postoperative pain is due to inflammation: inflammation from the incision, inflammation from the tissue dissection, and the mesh also adds to the inflammation.
THE BEST TREATMENT FOR INFLAMMATION? ANTI-INFLAMMATORIES.
Try ice. A simple ice pack over your incision can dramatically reduce the need for any pain pills. There is a wide option for anti-inflammatory medications, too.
Beside, narcotics contribute to constipation, which is a strong risk factor for hernia formation. If you’ve ever experienced narcotics-induced constipation, you know what I am talking about. The straining can be painful. Now consider straining after a hernia repair. Pop go those sutures. Why would I sabotage my own repair?
The Journal of the American Medical Association, JAMA, published on the pervasive practice of prescribing narcotics for postoperative pain after “low-risk surgical procedures.” These operations include carpal tunnel release, laparoscopic cholecystecomy, knee arthroscopy and inguinal hernia repair. I’ve even seen it with hysteroscopy, cystoscopy, and vasectomy.
AS A HERNIA SURGEON, I AM ASTONISHED BUT NOT SURPRISED.
Imagine the impact to society if the majority of our operations did not involve the prescription of narcotics postoperatively. Do we as a medical society have to hit rock-bottom and fail our patients before we take it upon themselves to think twice before prescribing a narcotic? Let’s not forget that the trickle effect from our opiate epidemic is the rising heroine epidemic that is affecting all tiers of our society.
Since the opening of my hernia center, I have prescribed narcotics in less than 5% of my postoperative patients.
On a weekly basis, I teach and instill in my surgical residents in training that there is no need to prescribe narcotics postoperatively. I urge my colleagues to do the same.
MANY OF YOU MAY BE READING THIS IN DISBELIEF.
How can you possibly get pain relief after surgery without some Norco? Vicodin? Percocet? Well, it’s possible and we do it daily.
For the non-believers, let me assure you that my patients are not gluten-free vegans from Beverly Hills.
Over 80% of my patients are from out of town or out of state, and do not fit the granola Southern California stereotype (I’m a SoCal-er, so I can say that). They are regular people just like you. They expect good pain control and do not want to suffer after surgery.
My colleagues disagree with me. Some claim their patients demand narcotics after surgery. They ask for Percocet by name. Also, they admit to me, “I just don’t want to be called,” after surgery for pain control issues.
HERE IS MY RESPONSE:
- Positive reinforcement is key. It is so uncommon in the US for a patient to leave an operation without a narcotic prescription in hand. We discuss your pain management plan ahead of time and review your expected recovery. We then tailor your pain regimen to your needs.
- Pre-emptive analgesia is best. I recommend early initiation of anti-inflammatory medication. That means, start the anti-inflammatory regimen prior to the date of your surgery. Safe ones include Arnica and Bromelain. These are excellent anti-inflammatory homeopathic regimens that do not interfere with surgical healing, bleeding, or any other medications.
- During surgery, I inject local anesthetic before making any incision. This has been proven to be beneficial regardless of the type of anesthesia (general or local with sedation). This is another mode of pre-emptive analgesia in my practice.
- Surgery is a delicate procedure. The tissue should be handled with a delicate touch. Much of the pain, swelling, and bruising after surgery is related to the amount of tissue trauma. A gentle surgeon’s touch can reduce your pain. I teach this to my medical students and surgical residents in training, as it is easy for them to forget that the patient is under anesthesia and cannot tell you that you’re pinching or pulling too hard on their tissues.
- It is cheap, easy, and highly effective. Everyone gets an ice pack from me. Place your ice pack directly on your wound for the first 1-2 days after surgery. It helps reduce pain, swelling, bruising. One French study even recommended starting the ice pack on the wound an hour before surgery.
- Resume an anti-inflammatory regimen immediately after surgery. Most of my patients get a dose of an IV anti-inflammatory (Toradol) at the end of their operation. In addition to ice, my choice for post-operative anti-inflammatory regimen includes Naproxen, Arnica, Bromelain, Alpha Lipoic Acid, Ginger, Turmeric, and Super B complex.*
- My non-narcotic regimen works for most, but not for all. About 15% of my patients suffer from moderate to severe chronic pain from their hernia or hernia-related complication. They often have their own Pain Management specialist who has been managing their pain. About half the time, my patients with chronic pain follow my non-narcotic regimen in addition to their baseline treatment, and they feel the difference.
- For the non-believers: I don’t get many calls for pain control issues. And my patients are super satisfied with their pain control.
THE BEVERLY HILLS HERNIA CENTER HOMEOPATHIC ANTI-INFLAMMATORY REGIMEN
- Ice packs
- Arnica Montana
- Alpha Lipoic Acid
- Super B Complex
I STRONGLY BELIEVE
Surgeons play an important role in our society. We should set an example and practice medicine with the society’s best interest in mind. It is common knowledge that a large fraction of people who are addicted to prescription drugs were first exposed to it after an operation, such as a simple knee arthroscopy. Many others were prescribed narcotics upon discharge from the Emergency Room, where they complained of belly pain, or perhaps they had a fall. This problem is real and it is worsening every year. It is hitting all classes of families. It is happening in your home town. I highly recommend you watch the 60 minutes special, “Heroin in the Heartland.” It is an eye-opening segment on the US heroine epidemic, and it clearly stems from the overuse of prescription drugs. They did a fantastic job to show how real and close-to-home this problem really is.
I am proud to claim that I am not perpetuating this epidemic.
* I did not come up with this homeopathic regimen on my own. I was first exposed to it by a Pain Management specialty colleague of mine, Dr. Laura Audell, who had very happy patients. Her patients appreciated that she didn’t “throw some narcotics” at their pain and instead integrated homeopathics into their pain control. Her patients appreciated this tailored approach, and now so do mine.
The regimen I use is evidence-based. Every homeopathic regimen has been studied and shown to be of value. There are many more supplements with which I do not yet have experience. Some are a combination of multiple homeopathics. Topical creams are also a great option, such as Traumeel and Aspercreme, as they provide local pain therapy. I do not recommend them over a fresh surgical wound, however.
–Dr. Shirin Towfigh is a world-renowned hernia specialist, Board Certified surgeon, and President of the Beverly Hills Hernia Center.