When It Comes to Post-Surgical Opioid Tapering, You’re on Your Own!

For most of 2023, I’d put off having back surgery—hoping against all odds that cortisone injections, monthly doses of oral steroids, strengthening exercises, and using a transcutaneous electrical nerve stimulation (TENS) unit might make the awful sciatica pain disappear. I had a number of major commitments that year that I needed my energy and strength for—my daughter’s July wedding being chief among them. Then there was my annual trip to the beach in August and a long-planned trip to England and Scotland in October. I’d managed to time the cortisone injections so that I could attend each of those events and be nearly pain-free, but by December when I took a daytrip to DC to see an exhibit on the Titanic, I was in such pain that I couldn’t stand more than five minutes at a time. I knew it was time to find a surgeon and finally face the inevitable.

My sports medicine doctor referred me to a few surgeons that he felt were good, and several friends suggested doctors who’d performed similar back surgeries. After MRIs, x-rays, and physical exams to determine that I needed a laminectomy and a lumbar fusion, two surgeons gave me two opposite opinions—one said he didn’t think my recovery odds were high enough and the other said to have the surgery and I’d be fine. I sought out a third opinion from Dr. L, a surgeon who is the head of his orthopedic department and also teaches in a medical school. He assured me that he’d operated on numerous people who had similar problems to mine, and he felt certain that I’d have good results and a smooth recovery. He had an opening in two weeks, so I scheduled my pre-op physical and blood tests.

One of my main concerns was adequate pain management after surgery (acute pain). During that initial consultation with Dr. L, I told him that there were two pain meds I had trouble with in the past: Percocet had made me extremely nauseated, and Vicodin had caused me to faint. Because of all the alarming publicity around the drug OxyContin (oxycodone with extended release capability), I was almost afraid to say that oxycodone had worked for me—would I sound like I was “drug-seeking?“ But I plunged ahead and told him, “I’m not asking specifically for this drug, but in the past oxycodone worked well and didn’t make me overly nauseous or light-headed. I had no trouble discontinuing it.” He smiled at me and said, “Don’t worry. We’ll find something to help you with your pain.”

A nurse practitioner named J conducted my physical and went over likely pain management after surgery. “We usually use some kind of opioid to help with discomfort, along with extra-strength Tylenol and gabapentin for nerve pain,” she told me. “I don’t want to take gabapentin since I know it can have a lot of adverse effects and is often difficult to discontinue. Can’t I use something else?” J explained that since the surgery usually disturbed a lot of nerves, people often had severe nerve pain. I nodded and countered, “I’ll hold gabapentin as a last resort if nothing else works. I’d rather use a muscle relaxant.” She smiled at me and typed something into the computer.

On the morning of the surgery, I saw Dr. L when he came to say hello, have me sign the consent forms, and mark the correct side of my body for the procedure. Soon after, I briefly discussed post-surgical pain management with the anesthesiologist, telling her, “I’ve read that pain pumps and epidurals can be helpful for pain after surgery. Are either one of those possibilities for me?” She mentioned using gabapentin, and I reiterated what I’d told the nurse practitioner. She typed something in the computer before assuring me, “Don’t worry. We’ll give you something to manage the pain.” So much for informed consent, I thought. But right before someone puts you to sleep for six hours so a surgeon can rearrange your spine is not the time to assert your rights as a patient. I simply had to trust them, and I knew if I needed more help, my kids would be there to advocate for me when I woke up.

The morning after surgery, two residents came into my room, cursorily examined me, asked me how I was feeling, and then began telling me about medications while I was in the hospital. “Well, we’re giving you oxycodone, extra strength Tylenol, an antinausea medication, lidocaine patches, and we’d like to add some gabapentin for nerve pain.” What was going on? I’d already made my wishes clear to two other providers, who seemed like they heard me and wrote down my preferences. I think I was more afraid of the gabapentin than the opioids at that point, so once again I made it clear that I wanted a muscle relaxant and if that didn’t work, I’d consider gabapentin as a last resort. It took three conversations with three different people, but there was no more mention of that dreaded drug. In the course of writing this article, I discovered that gabapentin is nearly always part of the medication package doctors recommend after spine surgery as a way of reducing reliance on opioids.

Four days after surgery, I felt like my pain was pretty well controlled with the drugs I was taking, and I looked forward to being at my daughter’s house for a few days before going back to my own home. A nurse practitioner from the surgeon’s practice came into my room to go over the prescriptions I’d be sent home with and gave me an information packet on what to do for my at-home care. She also told me that the Home Health Care Team would call me to arrange for physical therapy. After she left the room, one of the hospital pharmacists called to go over my prescriptions—and their cost— and to my surprise he said, “We’ll also be sending you home with naloxone (an anti-overdose drug) and that will cost you $100.” I was completely shocked. and answered firmly, “I’ve never had a problem with abusing drugs, and I’m well aware of the risks associated with oxycodone. But as for naloxone, I live alone, so if by some remote chance I did overdose, no one would be there to rescue me.” That very brief exchange with the pharmacist was the only conversation that anyone had with me that even hinted at the possibility that I’d be taking a potentially dangerous drug.

I quickly realized that the drugs I was taking—probably the oxycodone and Robaxin (muscle relaxant)—impacted my memory to the point where I had to write down the time for each dose and then check it off once I’d taken it. The nurse practitioner had sent me home with enough oxycodone for about 10 days, but I quickly found I didn’t need the 10 mg dose very four hours and cut it down to 5 mg per dose instead. I also found that using ice packs, warm showers, and lidocaine patches greatly helped me to manage any pain and discomfort. I don’t know if most of the pain that I experienced was nerve pain or pain from the staples used to close my incision, but a few days after the surgeon’s Physician’s Assistant (PA) removed the staples, I felt ready to begin tapering the oxycodone with the goal of getting off by the end of April.

Anytime I needed a prescription refill, I sent a message through MyChart (an online medical records and communication platform used by many doctors and hospitals) to the PA. Once I decided to taper off the oxycodone, I sent her a message and said I ‘d like to discuss tapering and pain management. She sent me a refill, but she never offered to discuss either tapering or pain management, besides saying to use extra-strength Tylenol. I admit that from all that I have read about abrupt tapering of psychiatric drugs combined with the generalized fear about opioid addiction and misuse, I was a little afraid that the PA would try to taper me too quickly, so I resolved to find a guide on my own.

When I began to look into the opioid tapering process, most of the articles I found dealt with tapering for people with opioid use disorder (OUD) who had usually been using opioids for a long time and experienced “clinically significant distress or impairment, including an overpowering desire to use opioids, increased opioid tolerance, and withdrawal syndrome when opioids are discontinued.” After several searches, I finally found a resource published by the Hospital for Special Surgery in New York that spoke to my situation of short-term, acute use and made this recommendation: “A tapering plan may be beneficial for patients who have been taking opioid medications multiple times a day for more than two weeks but less than six months.”

The article provided the example of patient taking eight pills divided into four doses per day. They recommended tapering by 10-25% every three or four days and then lengthening the time between doses from every six hours, to every eight hours, then every twelve hours, and taking the final dose at bedtime for a few days before entirely discontinuing the drug. Additionally, the authors included a section dealing with non-pharmacologic ways to manage pain such as staying adequately hydrated, eating a balanced diet on a regular schedule, exercising, mediating, and maintaining a positive outlook. They specifically warned against using alcohol in place of any of the opioid drugs.

For the first three weeks of my taper, I cut the dose by one half of a single 5 mg pill (2.5 mg) every three days and continued on a four-dose regimen for almost three weeks. By then, I was down to 2.5 mg three times a day for several days and then I cut the dose to 2.5 mg twice a day and 1.25 mg for the third dose. I continued cutting the dose by 1.25 mg every few days until I got to a once per day dose, which I took at bedtime for a few nights before finally discontinuing all the opioids.

The tapering process took me six weeks to go from 20 mg/day of oxycodone down to zero, and at no time did I experience any withdrawal symptoms. I was a little nervous that my sleep might be disrupted, but all went well in that area. What I loved about not taking any more opioids was that I felt more energetic and more motivated to pursue my interests.

But one thing nagged at me the whole time: My providers didn’t offer to help me taper, even when I asked. Additionally, the written information provide to me was contradictory about how long it was deemed acceptable to use opioids post-surgery, with one source saying no longer than three month and the other saying no longer than two weeks. Finally, not only didn’t my providers help me, but when I spent time figuring out how many pills I’d need to finish my taper and told the PA I needed a refill for twelve more pills, she gave me thirty.

Something didn’t add up for me. It’s highly probable that anyone living in the United States for the past twenty years has at least a passing knowledge about the dangers of opioid use. I’d read several books on the issue and even written about my own experience of being overmedicated with opioids and psychiatric drugs here and here. Most people who paid attention to any news at all heard numerous reports about the increasing overdoses and deaths from opioid use and on the opposite end of the spectrum, numerous sources covered the problems some people had with getting any pain medicine at all. And despite my doctors wanting to send me home with a prescription for Naloxone to treat an overdose, they never had a conversation with me about the potential hazards of opioid use nor did they help me to discontinue the drug when I asked.

I wondered—Is this kind of treatment common or did I just have a one-off experience? The more I delved into the questions of educating patients about pain management, prescribing opioids, and tapering after surgery, the wider the gap grew between what the research recommended and what I’d experienced as a patient.

There’s a Problem With Postsurgical Opioid Prescribing and Tapering

How big of a problem is post-surgical opioid use? What I discovered served to convince me that my concerns were warranted. A study published in Orthopedic Reviews by Kevin Bernardino et al. discovered that in the United States, 98% of the patients are prescribed opioids after surgery and a majority of them receive more pills than they need. The same study revealed that 40% of the excess opioids aren’t disposed of properly, leading to an opportunity for diversion or use by someone never prescribed the drug. Orthopedic and neurosurgery have the highest rates of opioid use, with spinal procedures like lumbar fusion, which I had, intersecting both of those specialties.

According to estimates from the Centers for Disease Control and Prevention (CDC), 81,000 people died of overdoses in 2020, most of which were accidental. The authors state clearly where the responsibility lies: “Most illegal opioid use starts with prescriptions, pointing to the critical responsibility that healthcare workers, in particular physicians and prescribers, may have in this crisis.”

While I did not use any opioids for pain relief prior to surgery, Bernardino et al. found that between 10-70% of spinal surgery patients do. And the after surgery, numbers are equally concerning with 52% of patients who used opioids chronically before surgery still using them at 12 months post-op compared to only 18.3% of opioid naïve patients (people who have not used opioids in the three months preceding surgery, though definition varies among providers). Most concerning for me was the information that females are associated with higher rates of opioid dependence, are more likely to be prescribed and to use opioids, and seem to have higher levels of post-op pain.

So, with such clear evidence that surgical patients, especially patients undergoing major spine surgery, are using opioids for pain relief and many are continuing drug use for up to a year after surgery, what do providers say about both prescribing opioids and helping people taper? An article by Warner et al. entitled “The System Is Broken: A Qualitative Assessment of Opioid Prescribing Practices After Surgery” details doctors’ concerns about guidelines versus experience with opioid prescribing, time constraints, inconsistency with opioid tapering, and lack of process or coordination with the handoff of prescribing between surgeons and primary care providers.

The twenty doctors surveyed in this study said that while they were aware of the CDC guidelines on prescribing opioids, there seemed to be a lack of focus on prescribing for acute, post-surgical pain. Many of them said that their institutions had developed independent guidelines, and while the residents relied more on the guidelines, the surgeons relied on their years of clinical experience.

Another area of concern that providers mentioned was the challenge of helping patients set realistic expectations about postoperative pain. The doctors noted having conversations both pre-and postoperatively; some said that they told patients they wouldn’t routinely prescribe opioids past four weeks, saying something to patients like, “I don’t think we can make this pain go to zero…but we can help you.”

Additionally, there is a lot of variation in deciding who is responsible for opioid prescribing throughout the recovery phase—whether it remains the surgeon/resident/PA’s responsibility or whether there is a handoff to the primary care provider. No one mentioned any such handoff to me in the course of my care, and the surgeon’s PA managed all of my prescriptions for the two months that I needed them. I did see a note in my discharge papers to “follow up with primary care provider,” but no one ever clarified what they expected me to do beyond sending her an email saying that my surgery and recovery had gone well.

While the study’s authors noted that “patients frequently ask for tapering plans, the provided plans are often incomplete,” with doctors setting the expectation to begin tapering in two weeks, but providing no details on how to accomplish that. Most concerning were the doctors own statements about the challenges they face with tapering, including “time management and lack of knowledge” and “I don’t always know how fast we should taper opioids. If I had more tools, it would drive the conversation a lot better.” The authors found that hospital pharmacists could assist with tapering plans and “expressed comfort with developing tapering regimens… Pharmacists also expressed feeling underutilized in postoperative prescribing, despite wanting to be more involved.”

What Are Some Solutions?

Before I delve into what the research revealed about tapering, patient education, and pain management, the first thing that I’d advise is that all written recommendation and education materials for patients should be aligned. The pre- and post-surgery book my surgeon’s office provided was very helpful in many ways—what to expect before, during, and after surgery, what exercises to do, when to resume daily activities, how long would healing take, to name a few areas. But there was a glaring disconnect between that booklet and my discharge directions regarding opioid use and tapering. The surgeon’s booklet referenced a referral to a pain management specialist if you still needed pain meds at three months post-surgery and the discharge directions referenced use of only two weeks resulting in the same referral. Perhaps someone in the Pain Management office could work with the surgeons and the nurses to be sure that all written patient directions are consistent.

Patient education plays a key role in helping people manage pain—and I would highly recommend at least one such conversation between a provider and a patient. This conversation could be scheduled either during a pre-surgery office visit or in the hospital before discharge. Dr. Scott Weiner, writing for the Harvard Health Blog, summarized a few of the key takeaways for pain education from the from the 2022 CDC Clinical Practice Guidelines for Prescribing Opioids For Pain. While the guidelines outlined are focused primarily of opioid use for chronic pain, a few of the points also apply to acute (post-surgery) pain management:

• A provider should explain the complex nature of pain and help the patient set expectations for postoperative pain.
• Providers and patients should judge what treatment is best, rather than setting strict limits on dosage.
• Start with the lowest possible dosage for the shortest amount of time to balance benefits and risks of opioid use.

As I read Weiner’s recommendations above, I thought that it would have greatly helped me to have had such a conversation with a nurse, doctor, or PA to go over the practices they recommend. Patient education, such as what Weiner recommends, is also an important component of a protocol designed in 1997 called enhanced recovery after surgery (ERAS), a series of recommended practices  to help patients manage pain, shorten hospital stays, and reduce the use of opioids.

Once I decided to have the spine surgery, my principal concern was pain management during recovery. Like most people here in the United States, I was aware of the dangers of taking too many opioids, but the only other pain management tools I was aware of were over-the-counter pain relievers, ice packs, and deep breathing. And I didn’t have much faith in my ability to control pain without opioids. Until I stumbled on Dr. Amy Baxter, a pediatric emergency room physician and pain researcher focusing on ways to reduce the use of opioids, and watched her TedTalk  “How to Hack Your Brain When You’re in Pain.” Honestly, if hospitals and doctors wanted a quick way to educate patients on pain management and alternatives, Baxter’s sixteen-minute video would be ideal.

Here are just a few pieces of information that Baxter presented in her video that could be useful in educating patients about pain and how to control it. Many of us, doctors included, tend to look at pain as an alarm to be silenced, but what if we viewed pain as a learning system for the brain? Think of teaching a child not to touch a hot stove—if they check it out for themselves, they quickly learn not to touch it. Or if they are curious about bees and swat at them while playing outside, they might get stung, so they learn to leave the bees alone.

For too long, patients have been sold the goal of being pain free, rather than being given tools to move past pain and manage it effectively. Baxter explains that physiology, fear, and control all intersect with pain, and shows us how to use a variety of tools to gain some mastery over it. Her website features a wonderful booklet, “What Works for Pain,” that patients can use to explore a myriad of pain management tools. Her booklet encourages patients to learn how to layer multiple options like over-the-counter medications, natural and herbal supplements, physical activity, and brain-body solutions. When patients are given a list of possible solutions, they can have more confidence in their ability to control their pain. I know I would have loved to have Dr. Baxter’s booklet to supplement the few techniques I knew about.

Another organization, The Overdose Prevention Engagement Network, has put together a pain education and management booklet for patients called “Adult Surgery: Pain Management Guide for Patients” that covers many of the same things as Dr. Baxter’s guide, and they do an especially good job of educating patients up front, prior to surgery, about setting realistic goals for pain management.

As I look over all the information that I’ve found about reducing opioids, helping patients taper, and alternative ways to manage pain, I have an idea for how to improve the current situation. Two limiting factors in almost all medical care are adequate time for patient care and giving patients appropriate information so they can recover successfully. The hospital where I had my surgery has an excellent home health care department that provides in-home physical therapy and nursing care. The physical therapist I worked with was extremely helpful in guiding me with mobility and checking on my incision healing.

Using a similar model, I’m going to suggest that hospitals create a team of visiting nurses who provide at least one in-home visit with patients who take post-surgery opioids. The nurses would be able to work with the patient on pain relief and design an individual tapering program when it’s appropriate. That way, the surgeon and their team do not have extra duty and the patient can have a knowledgeable and dedicated point-person that can help them with a critical piece of their recovery.

All along the way, I have firmly believed that the people who give patients drugs-surgeons in this case—have a responsibility to help people get off the drugs. Just like I think psychiatrists should know how to help their patients taper. I still believe that, and with so much research available, it shouldn’t be up to patients to find their own path out of pain and drug use. But while we wait for the doctors to align their practices with the widely available research, I hope some hospitals will dedicate funds to creating teams of nurses who can do the critical work of pain management education and drug tapering assistance.