November 20, 2025 • 21 mins
In this episode, Tom Varghese, MD, FACS, is joined by Ziad Sifri, MD, FACS, from Rutgers New Jersey Medical School, and Matthew Linz, MD, from Rutgers Robert Wood Johnson Medical School. They discuss Drs Sifri and Linz’s recent article, “Postoperative Pain Management in the US vs Low- and Middle-Income Countries by US Surgeons,” in which they found that surgeons in the US prescribe significantly more opioids after inguinal hernia repair compared with when they operate on short-term surgical trips to low- and middle-income countries, despite continued efforts to reduce opioid overprescription in the US.
Disclosure Information: Drs Varghese, Linz, and Sifri have nothing to disclose.
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Linz, Matthew S MD1; Parvin-Nejad, Fatemeh P MD2; Srinivasan, Nivetha MD3; Vegunta, Geetasravya MD1; Eng, Ashley K BS1; Kim, Eugene BA MBS; Alexander, Imani BS1; Elgammal, Fatima MD2; Benson, Ryan MD2; Benneh, Albert Y MD4; Gyakobo, Mawuli K MD5,6; Lopez, Lorena MD7; Jalloh, Samba MD8; Sifri, Ziad C MD FACS2. Postoperative Pain Management in the US vs Low-and-Middle-Income Countries by US Surgeons. Journal of the American College of Surgeons ():10.1097/XCS.0000000000001538, July 30, 2025. | DOI: 10.1097/XCS.0000000000001538
Learn more about the Journal of the American College of Surgeons, a monthly peer-reviewed journal publishing original contributions on all aspects of surgery, including scientific articles, collective reviews, experimental investigations, and more.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:03):
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian
Erdahl and I will speak with recentlypublished authors about the motivation
behind their latest researchand the clinical implications
it has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Welcome loyal listenersto another episode of The Operative
Word, the podcast for the Journalof the American College of Surgeons.
I'm your host for today's episode,Tom Varghese.
I'm a thoracic surgeonat the University of Utah,
and I also have the honorof being the editor in chief
(00:47):
for the Journal of the American Collegeof Surgeons.
I'm joined by two incredible people todaythat we're going to take your time
to talk about this recentlypublished article in the Journal of the
American College of Surgeons entitled“Postoperative Pain Management in the US
vs Low- and Middle-Income Countries by USSurgeons.”
We're joined by the first authorof this article, Dr Matthew Linz,
(01:10):
as well as the senior author of thisarticle, Dr Ziad Sifri, both from,
Rutgers New Jersey Medical School,and I will have them introduce themselves.
Dr Linzgo ahead and say hello to our listeners.
Hello, everyone.
My name is Matt Linz.
I am a general surgery resident.
I'm actually now at Rutgers Robert WoodJohnson Medical School, so I switched from
(01:32):
the Newark campus to New Brunswick, butstill within the Rutgers health system.
You guys are like all across the street
from each other,so it's hard to keep track.
But I got it, Dr Linz.
Thank you for having me.
Dr Sifri if you can go aheadand introduce yourself to our listeners.
Hi, everybody. My name is Ziad Sifri.
I'm a trauma surgeon, chief of trauma
and critical care at New JerseyMedical School in Newark, New Jersey.
(01:53):
Thanks for having us.
Thank you both for joining us.
And any financial disclosuresfrom either of you for this work?
None for me. I wish.
Okay, perfect.
Well, let's get started.
Well, thank you all for joining us.
This is a fascinating topic.
And, you know, obviously,
the opioid epidemic has beenon a lot of people's minds,
(02:16):
from the local, regional, national andinternational levels for quite some time.
And this epidemic has been burningor around for several years now.
And I think it's amidstthis backdrop that this particular work,
is has been brought forward for,
you know, you know, for example,your opening sentence in your abstract
(02:38):
says, “Despite an ongoing opioid epidemicin the United States, opioids
remain overprescribed after surgerycompared to the rest of the world.”
Let me start first from there.
Why did you embark on this project,
or how did you even come up with the ideato do this project in the first place?
Dr Linz or Dr Sifri, why don't yougo ahead and, tackle that question?
(03:01):
Yeah. So I think you're right.
The opioid epidemic is a huge crisis.
I think I say this in the paper,and there's about 80,000
deaths from opioid overdose in 2021.
And in a more recent study, there's 130
million opioid prescriptionswritten every year.
That's from our 2022 data.
(03:23):
And we know the consequences.
We know how significant this problem is.
And sometimes, insteadof focusing on ourselves to come up with
solutions, focusing on the outsidemeaning the international scene,
and comparing what happens abroad
as a way to learnand bring solutions back to the US.
(03:44):
So the idea kind of started,from basically anecdotally, just
I remember a patientwho needed emergency surgery who was
and they're 70 and,we didn't have much narcotic.
It was an incarcerated herniawith dead bowel.
And we really had very little narcoticto give this patient.
And what struck me the next daywhen we came to see him, not knowing if he
(04:07):
was going to even survive the night,he was awake, sitting in his chair, alert,
and he had bowel functionand really struck by, you know,
how patients behavewhen narcotics are limited.
And some of the benefits we,we see after that, we,
started doing our annual, mission
trips to, to Ghana and other countrieswith limited narcotics.
(04:31):
And it was very obviousthat we could control pain much better
or well enough with limited narcotics,
supplemented by a lot of nonopioid solutions.
And what we decided after a couple of years is to go back and look at the data and,
quantify it as well as compare itto our practice in the US
(04:52):
so we could learnpossibly some lesson from
what happened abroadwith what was happening in our backyard.
And I guess one of the questionsthat naturally comes from that is,
this was kind of a convenient sampling,but it was one of those things where,
your group,the organization, were already doing
(05:12):
these short-term surgical tripsto Ghana, Peru and Sierra Leone.
And then you realize thatthese same surgeons going on the trips
are also obviously busy practicingsurgeons here in the United States.
Is that a correct way of framing in termsof the opportunity to do the study?
Yes. That's correct.
Perfect.
(05:33):
Good.
Tell us more about the methodology, DrLinz, if you want to tackle that question.
Like about,
you know, howyou went about identifying this because
obviously here in the United States,where there's
a lot of electronic medical recordsand things are easy to search.
I'm just curious about how hard it wasto do this in these countries.
Like, I'm assuming there's probablya wide variability in terms of record
(05:55):
keeping or additional informationthat you had to seek.
Absolutely. So,
in addition to everything Dr Sifri alreadysaid, I also wanted to mention that,
this project was
also supported by the Global Health
Distinction Program at New JerseyMedical School.
Rutgers does a very good jobat supporting student research.
(06:17):
And I would say that,
Dr Sifri has already doneplenty of research
more focused on the,
international side of thingsin Ghana and Peru and Sierra Leone.
And so we already had pretty robust recordkeeping on that side.
And when I joined the Global HealthDistinction program,
I had an idea that I wanted to work onsomething related to post-operative pain,
(06:40):
and it kind of just naturally morphedinto this project,
kind of with discussions with Dr
Sifri over the course of several months.
So this was a multi centerretrospective cohort study.
We looked at Sierra Leone,we looked at Peru, we looked at Ghana,
these hospitalswhere we were going basically every year.
(07:02):
For these short-term surgical trips.
And then we looked at those same years
at our homehospital, the academic teaching hospital
affiliated with New Jersey Medical School,which is University Hospital in Newark.
It was an IRB approved study.
A lot of medical students were involved,as well as some residents.
And basically the,we started with just open
(07:24):
inguinal hernias, because that was howwe kept it simple enough
that it was similarbetween all the different sites.
And we excluded emergent procedures.
We excluded any sort of complicated cases
where there was any additional procedurebeyond just the inguinal hernia repair.
And we also excluded patients who hada length of stay longer than seven days,
(07:47):
because we figured they were more likelyto have
some sort of other comorbid
medical issue or had a complication.
And so we looked at the pain scores,the opioids prescribed
within 24 hours, the non opioid painmedications prescribed within 24 hours.
And we looked at opioids on discharge.
(08:08):
And we did a little bit of backgroundresearch just to make sure.
But outpatient pharmacies with opioids
were availableat affordable cost to patients
not only in the US but in all of the lowand middle income countries.
And that said,I think there's a couple of,
really distinguishing characteristicsthat you I think you correctly and...
(08:28):
the same operations, both settings.
Your anticipation is straightforwardoperations.
I guess one question is, what was yourhypothesis and what was your gut instinct?
Were you thinking that there was goingto be huge differences,
or were you thinking there were going tobe similar patterns going in to the study?
So we suspected that it would probably
(08:49):
the disparate there would be a disparity,but it would get better over time.
And what we saw is that statistically,it actually didn't change over time.
And for a reminder of thethis is from 2013 to 2019.
So this is not a short period of time.
You're doing this over multiple trips,over an extended period of time
and everything else that.
(09:10):
Yes, all of thatis correct. 2013 and 2019,
so included a fair amount of cases.
And, yeah, we were surprised thatwe didn't see a change
over time that this disparity persistedduring the study period.
And let's get right to the findings.
I mean, so, at least in your abstract,you you said that, you know, obviously,
(09:31):
this was an analysis of,about 558 patients.
And, I mean, I was blown away.
I mean, I, I was expecting a little bitdifferences, I'll be honest with you,
but it was really dramaticin terms of the opioid
prescribing habits or at least the opioidsthat the patients were prescribed.
Well, Dr Linz,if you wanted to extend further on that,
(09:53):
but let's talk about the findings,from the study.
Absolutely.
So the main findings were thatwe saw that US patients
received about ninefoldmore opioids in their 24 hours
after surgery, compared to patientsin, Peru, Ghana and Sierra Leone.
Sites, and 90-fold more opioidson discharge from the hospital.
(10:15):
And there was also much greater variability for opioid prescriptions in the US.
And so our
kind of takeaway fromthat was that even though there's already
a lot of multimodal effortsto reduce opioid prescriptions
after surgery in the US,there might still be room
for further changes to attenuate opioidsafter surgery.
(10:36):
You know, I do want to expandon a couple of clarifications.
And, I think either you or DrSifri can address this.
You know, so the myths out
there are it's, a supply issue,
like opioids are more readily available,in the US as compared to other countries.
But you all did the extra stepto make sure that that wasn't the issue.
(11:00):
Right.
You made sure that there were opioidsavailable.
If the surgeons chose the prescribed.
Correct.
So, yes.
And Dr Sifri, I'm sure will have thoughts
because he's had more experienceat these outside hospitals.
But yes, I mean, there are outpatientpharmacies with opioids available
at a reasonable cost.
(11:21):
I would saythe supply is probably more limited
in low- and middle-incomecountries than in the US.
But they are available.
And with the backdropof we're talking about
open inguinal or hernia repairs,
pretty much the preoperative
education, expectation setting,all the other things that go
(11:42):
along with this, because you chose thisas your index case for comparison.
There weren't like massive differencebetween the two groups.
Am I correct in stating that as well.
Correct.
Yeah.
I just want to becomejust want to add one thing.
I think,
one of the main factorswe focused on the paper,
(12:04):
related to the use of,narcotics was pain control.
It was really importantfor us to establish that the patients had
a satisfactory pain scoreand this kind of,
really pushed us to documentthe pain scores of patients
as they were navigatingthrough the postop period.
And it was really importantfor us to demonstrate that,
(12:26):
you know, the lack of narcoticsdidn't result in,
you know, out of control pain,that the pain remained well controlled.
I think
the extent of the difference,as Matt said, between the US
and our trips was very striking.
We didn't we expected the difference,but not to such a big difference.
And I think the one thingwe didn't emphasize enough in the paper
(12:49):
is the non-opioid treatmentthat those patients received,
whether it was NSAIDs or Tylenolor other treatment that we instituted
to supplement their pain management,which I think resulted in there
being control being satisfactoryand reducing the overall amount
of narcotic in multiple forms, which was,I think,
(13:11):
the most striking part of these results.
And that's incredible.
And it just kind of reminds me of so,
same surgeons,
different countries,of course, the same surgical procedure.
But one of the findingsyou did pull out in the paper were,
correct me if I'm
wrong, butit said that almost 50% of the US patients
(13:34):
were not opioid naive,meaning they had received opioids before.
Do you think that that'sone of the factors, meaning that,
you know, if you've received opioidsbefore you come in, potentially
with an expectation of you need opioidsfor pain control afterwards?
I think that's probablya confounding factor for sure.
(13:55):
Obviously it's hard to tease that out.
Yeah. With a retrospective study.
But I do think and maybe I'm jumpingthe gun a little bit here, but
prospective studieslooking at opioid free analgesia
for specific proceduresis probably a worthwhile endeavor.
Yeah. In this area.
And your perspective,I mean, I think that I mean,
(14:18):
you've been doing these trips for,you know, decades now and you've kind of
seen the evolution of, you know,from the start of launching these programs
to now a lot of these programsare robust in themselves.
In terms of the practice environment and,
you know, the openness to receivepatient education and things like that.
There's not massive cultural differencesbetween the different countries.
(14:41):
Correct.
In terms of launching projects like this.
Yeah. It's interesting.
I think a couple of thingsthat are important.
I definitely agree with Matt.
It definitely plays a role.
Prior narcotic use in terms of,
your, need for narcotic.
And I think from overall,from a public health perspective,
(15:01):
reducing prior exposure to narcoticis something
big picture we should be aiming atbecause that's going to reduce,
I think, your need for narcoticif you need surgery.
But there are cultural differences.
And I think that evenwhen Matt was analyzing different sites
that the same NGO was visiting,
(15:22):
the amount of narcotic consumptionand prescription varied,
and that has to do with the population.
I think there is cultural differencesin terms of the interpretation
of pain,the tolerance for pain, the resilience.
I think some of it is embeddedin the culture.
Some of it is, you know,you have no choice but to be resilient
(15:45):
when you're living in an environmentthat's so harsh.
And I think people are extremely,
excited to get their hernias repaired.
And a lot of time,they're willing to tolerate, pain,
because the environmentthey live in is, often requires it.
And also they want to make surethat their recovery is happening smoothly.
(16:08):
So culturally,I think there's definitely a factor.
I think education and setting expectationearly on is another thing
we can learnand bring back to the US in terms of,
you know, what are our expectationfor pain control after a surgery
and what is what should be toleratedversus what you know should not exist.
And I think these are some of the thingswe've been discussing and talking about
(16:32):
as far as, you know, some of the lessons,
in pain toleranceand cultural differences.
Those are those are amazing, perspectives,
in the small amount of timethat we have left,
I did want to cover one additional thing.
So this is in the concluding paragraphof this amazing manuscript
that has been published in JACS,the statement, you say that “Our findings
(16:53):
suggest that even with national effortsto reduce
opioid prescriptions after surgerythrough educational initiatives,
prescribing guidelines and standardizedpatient instructions,
other changes urging the further attenuateof opioid prescriptions
in the US might be necessary.”What are your thoughts?
(17:14):
I mean,I think that there's prospective studies.
There's a lot of different thingsthat you can think about.
But where should we start?
Because we thought,okay, let's raise the awareness.
And through an educational initiativethat should change the thing.
Probably a little bit of behaviormodification.
Not a lot.
We thought that publishingthese guidelines, that should
(17:34):
certainly lead to changeand that didn't do it.
And then, as you correctly pointed out,you had standardized patient instructions
and that didn't do it.So I guess what's next?
I mean, is it bundles of therapy?
Is it,you know, rolling into another program?
I'm just curiousas to where you think we should go next.
Yeah, I think Tom, you point to the fact
that this is a complex,multifactorial problem.
(17:57):
There isn't one solutionthat fits all the issues.
I believe there's, articlecoming up in JACS next month
that talks about opioid stewardship,
by Dr Alexa Melucci.
She's the first author,and I think they have a, you know,
stewardship program that has resultedin significant reduction in their use.
(18:18):
But I think, you know, the solutions,
that have
partially shown some effect: awareness, education, guidelines, (18:23):
undefined
have been out there,but I think we need a better solution.
I think that,
reducing the exposure, with,
increasing the non-opioid interventionis something we haven't worked on enough.
And there's something of a gapwe see when we compare our use
(18:46):
compare here in Newark compared to LMIC,we need to decrease
not only narcotic but we use alternativemethods non-opioid options
whether it's ice or NSAIDsor others, Gaba, etc.
to kind of manage the painin a way to avoid opioids.
Amazing.
(19:07):
You know,I think that, obviously I’m biased
I mean, we love seeing this publishedin JACS, but I think that really I'm
hoping that this is the startof a continuing conversation.
So, and I don't in any way meanto minimize any of the efforts we've done
so far in terms of raising awarenessand the guidelines and the,
(19:28):
educational,you know, you know, patient instructions.
I just I think that this,this is a phenomenal study in terms of
doing a snapshot, aspect of where are we
right now and where do we need to go?
Dr Linz,since you you're the youngest amongst us.
I'll leave you with the final words.
Hopefully this has wet your appetite interms of doing this type of academic work.
(19:50):
And I'm hoping that you will continue towork with Dr Sifri for going forward. But,
any final comments to Dr Linz in termsof, your reflections on this project?
Yeah.
I think there's a lot of room forcontinued improvement in this space. And,
I look forward to
working with Dr Sifri and hopefullysome other collaborators too,
(20:11):
to continue, work in this effort
to reduce opioids after surgery.
Well, on behalf of all of our incredible,
loyal listeners here at the Journalof the American College of Surgeons.
Dr Linz, Dr Sifri.
Thank you for doing this, incredible work.
Thank you for all your effortsin global surgery and, you know,
(20:33):
improving care for all of our patientsaround the world.
And, on behalf of all of us, gratefulthat you were willing
to share this workand get it published into JACS.
Thanks for sharing your time with ustoday.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
(20:54):
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to the operative wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at FACS.org/podcast.
You are listening to The Operative Word,
a podcast brought to you by the Journalof the American College of Surgeons.
I'm Dr Tom Varghese,and throughout the series, Dr Lillian
Erdahl and I will speak with recentlypublished authors about the motivation
behind their latest researchand the clinical implications
it has for the practicing surgeon.
The opinions expressed in this podcastare those of the participants,
(00:26):
and not necessarilythat of the American College of Surgeons.
Welcome loyal listenersto another episode of The Operative
Word, the podcast for the Journalof the American College of Surgeons.
I'm your host for today's episode,Tom Varghese.
I'm a thoracic surgeonat the University of Utah,
and I also have the honorof being the editor in chief
(00:47):
for the Journal of the American Collegeof Surgeons.
I'm joined by two incredible people todaythat we're going to take your time
to talk about this recentlypublished article in the Journal of the
American College of Surgeons entitled“Postoperative Pain Management in the US
vs Low- and Middle-Income Countries by USSurgeons.”
We're joined by the first authorof this article, Dr Matthew Linz,
(01:10):
as well as the senior author of thisarticle, Dr Ziad Sifri, both from,
Rutgers New Jersey Medical School,and I will have them introduce themselves.
Dr Linzgo ahead and say hello to our listeners.
Hello, everyone.
My name is Matt Linz.
I am a general surgery resident.
I'm actually now at Rutgers Robert WoodJohnson Medical School, so I switched from
(01:32):
the Newark campus to New Brunswick, butstill within the Rutgers health system.
You guys are like all across the street
from each other,so it's hard to keep track.
But I got it, Dr Linz.
Thank you for having me.
Dr Sifri if you can go aheadand introduce yourself to our listeners.
Hi, everybody. My name is Ziad Sifri.
I'm a trauma surgeon, chief of trauma
and critical care at New JerseyMedical School in Newark, New Jersey.
(01:53):
Thanks for having us.
Thank you both for joining us.
And any financial disclosuresfrom either of you for this work?
None for me. I wish.
Okay, perfect.
Well, let's get started.
Well, thank you all for joining us.
This is a fascinating topic.
And, you know, obviously,
the opioid epidemic has beenon a lot of people's minds,
(02:16):
from the local, regional, national andinternational levels for quite some time.
And this epidemic has been burningor around for several years now.
And I think it's amidstthis backdrop that this particular work,
is has been brought forward for,
you know, you know, for example,your opening sentence in your abstract
(02:38):
says, “Despite an ongoing opioid epidemicin the United States, opioids
remain overprescribed after surgerycompared to the rest of the world.”
Let me start first from there.
Why did you embark on this project,
or how did you even come up with the ideato do this project in the first place?
Dr Linz or Dr Sifri, why don't yougo ahead and, tackle that question?
(03:01):
Yeah. So I think you're right.
The opioid epidemic is a huge crisis.
I think I say this in the paper,and there's about 80,000
deaths from opioid overdose in 2021.
And in a more recent study, there's 130
million opioid prescriptionswritten every year.
That's from our 2022 data.
(03:23):
And we know the consequences.
We know how significant this problem is.
And sometimes, insteadof focusing on ourselves to come up with
solutions, focusing on the outsidemeaning the international scene,
and comparing what happens abroad
as a way to learnand bring solutions back to the US.
(03:44):
So the idea kind of started,from basically anecdotally, just
I remember a patientwho needed emergency surgery who was
and they're 70 and,we didn't have much narcotic.
It was an incarcerated herniawith dead bowel.
And we really had very little narcoticto give this patient.
And what struck me the next daywhen we came to see him, not knowing if he
(04:07):
was going to even survive the night,he was awake, sitting in his chair, alert,
and he had bowel functionand really struck by, you know,
how patients behavewhen narcotics are limited.
And some of the benefits we,we see after that, we,
started doing our annual, mission
trips to, to Ghana and other countrieswith limited narcotics.
(04:31):
And it was very obviousthat we could control pain much better
or well enough with limited narcotics,
supplemented by a lot of nonopioid solutions.
And what we decided after a couple of years is to go back and look at the data and,
quantify it as well as compare itto our practice in the US
(04:52):
so we could learnpossibly some lesson from
what happened abroadwith what was happening in our backyard.
And I guess one of the questionsthat naturally comes from that is,
this was kind of a convenient sampling,but it was one of those things where,
your group,the organization, were already doing
(05:12):
these short-term surgical tripsto Ghana, Peru and Sierra Leone.
And then you realize thatthese same surgeons going on the trips
are also obviously busy practicingsurgeons here in the United States.
Is that a correct way of framing in termsof the opportunity to do the study?
Yes. That's correct.
Perfect.
(05:33):
Good.
Tell us more about the methodology, DrLinz, if you want to tackle that question.
Like about,
you know, howyou went about identifying this because
obviously here in the United States,where there's
a lot of electronic medical recordsand things are easy to search.
I'm just curious about how hard it wasto do this in these countries.
Like, I'm assuming there's probablya wide variability in terms of record
(05:55):
keeping or additional informationthat you had to seek.
Absolutely. So,
in addition to everything Dr Sifri alreadysaid, I also wanted to mention that,
this project was
also supported by the Global Health
Distinction Program at New JerseyMedical School.
Rutgers does a very good jobat supporting student research.
(06:17):
And I would say that,
Dr Sifri has already doneplenty of research
more focused on the,
international side of thingsin Ghana and Peru and Sierra Leone.
And so we already had pretty robust recordkeeping on that side.
And when I joined the Global HealthDistinction program,
I had an idea that I wanted to work onsomething related to post-operative pain,
(06:40):
and it kind of just naturally morphedinto this project,
kind of with discussions with Dr
Sifri over the course of several months.
So this was a multi centerretrospective cohort study.
We looked at Sierra Leone,we looked at Peru, we looked at Ghana,
these hospitalswhere we were going basically every year.
(07:02):
For these short-term surgical trips.
And then we looked at those same years
at our homehospital, the academic teaching hospital
affiliated with New Jersey Medical School,which is University Hospital in Newark.
It was an IRB approved study.
A lot of medical students were involved,as well as some residents.
And basically the,we started with just open
(07:24):
inguinal hernias, because that was howwe kept it simple enough
that it was similarbetween all the different sites.
And we excluded emergent procedures.
We excluded any sort of complicated cases
where there was any additional procedurebeyond just the inguinal hernia repair.
And we also excluded patients who hada length of stay longer than seven days,
(07:47):
because we figured they were more likelyto have
some sort of other comorbid
medical issue or had a complication.
And so we looked at the pain scores,the opioids prescribed
within 24 hours, the non opioid painmedications prescribed within 24 hours.
And we looked at opioids on discharge.
(08:08):
And we did a little bit of backgroundresearch just to make sure.
But outpatient pharmacies with opioids
were availableat affordable cost to patients
not only in the US but in all of the lowand middle income countries.
And that said,I think there's a couple of,
really distinguishing characteristicsthat you I think you correctly and...
(08:28):
the same operations, both settings.
Your anticipation is straightforwardoperations.
I guess one question is, what was yourhypothesis and what was your gut instinct?
Were you thinking that there was goingto be huge differences,
or were you thinking there were going tobe similar patterns going in to the study?
So we suspected that it would probably
(08:49):
the disparate there would be a disparity,but it would get better over time.
And what we saw is that statistically,it actually didn't change over time.
And for a reminder of thethis is from 2013 to 2019.
So this is not a short period of time.
You're doing this over multiple trips,over an extended period of time
and everything else that.
(09:10):
Yes, all of thatis correct. 2013 and 2019,
so included a fair amount of cases.
And, yeah, we were surprised thatwe didn't see a change
over time that this disparity persistedduring the study period.
And let's get right to the findings.
I mean, so, at least in your abstract,you you said that, you know, obviously,
(09:31):
this was an analysis of,about 558 patients.
And, I mean, I was blown away.
I mean, I, I was expecting a little bitdifferences, I'll be honest with you,
but it was really dramaticin terms of the opioid
prescribing habits or at least the opioidsthat the patients were prescribed.
Well, Dr Linz,if you wanted to extend further on that,
(09:53):
but let's talk about the findings,from the study.
Absolutely.
So the main findings were thatwe saw that US patients
received about ninefoldmore opioids in their 24 hours
after surgery, compared to patientsin, Peru, Ghana and Sierra Leone.
Sites, and 90-fold more opioidson discharge from the hospital.
(10:15):
And there was also much greater variability for opioid prescriptions in the US.
And so our
kind of takeaway fromthat was that even though there's already
a lot of multimodal effortsto reduce opioid prescriptions
after surgery in the US,there might still be room
for further changes to attenuate opioidsafter surgery.
(10:36):
You know, I do want to expandon a couple of clarifications.
And, I think either you or DrSifri can address this.
You know, so the myths out
there are it's, a supply issue,
like opioids are more readily available,in the US as compared to other countries.
But you all did the extra stepto make sure that that wasn't the issue.
(11:00):
Right.
You made sure that there were opioidsavailable.
If the surgeons chose the prescribed.
Correct.
So, yes.
And Dr Sifri, I'm sure will have thoughts
because he's had more experienceat these outside hospitals.
But yes, I mean, there are outpatientpharmacies with opioids available
at a reasonable cost.
(11:21):
I would saythe supply is probably more limited
in low- and middle-incomecountries than in the US.
But they are available.
And with the backdropof we're talking about
open inguinal or hernia repairs,
pretty much the preoperative
education, expectation setting,all the other things that go
(11:42):
along with this, because you chose thisas your index case for comparison.
There weren't like massive differencebetween the two groups.
Am I correct in stating that as well.
Correct.
Yeah.
I just want to becomejust want to add one thing.
I think,
one of the main factorswe focused on the paper,
(12:04):
related to the use of,narcotics was pain control.
It was really importantfor us to establish that the patients had
a satisfactory pain scoreand this kind of,
really pushed us to documentthe pain scores of patients
as they were navigatingthrough the postop period.
And it was really importantfor us to demonstrate that,
(12:26):
you know, the lack of narcoticsdidn't result in,
you know, out of control pain,that the pain remained well controlled.
I think
the extent of the difference,as Matt said, between the US
and our trips was very striking.
We didn't we expected the difference,but not to such a big difference.
And I think the one thingwe didn't emphasize enough in the paper
(12:49):
is the non-opioid treatmentthat those patients received,
whether it was NSAIDs or Tylenolor other treatment that we instituted
to supplement their pain management,which I think resulted in there
being control being satisfactoryand reducing the overall amount
of narcotic in multiple forms, which was,I think,
(13:11):
the most striking part of these results.
And that's incredible.
And it just kind of reminds me of so,
same surgeons,
different countries,of course, the same surgical procedure.
But one of the findingsyou did pull out in the paper were,
correct me if I'm
wrong, butit said that almost 50% of the US patients
(13:34):
were not opioid naive,meaning they had received opioids before.
Do you think that that'sone of the factors, meaning that,
you know, if you've received opioidsbefore you come in, potentially
with an expectation of you need opioidsfor pain control afterwards?
I think that's probablya confounding factor for sure.
(13:55):
Obviously it's hard to tease that out.
Yeah. With a retrospective study.
But I do think and maybe I'm jumpingthe gun a little bit here, but
prospective studieslooking at opioid free analgesia
for specific proceduresis probably a worthwhile endeavor.
Yeah. In this area.
And your perspective,I mean, I think that I mean,
(14:18):
you've been doing these trips for,you know, decades now and you've kind of
seen the evolution of, you know,from the start of launching these programs
to now a lot of these programsare robust in themselves.
In terms of the practice environment and,
you know, the openness to receivepatient education and things like that.
There's not massive cultural differencesbetween the different countries.
(14:41):
Correct.
In terms of launching projects like this.
Yeah. It's interesting.
I think a couple of thingsthat are important.
I definitely agree with Matt.
It definitely plays a role.
Prior narcotic use in terms of,
your, need for narcotic.
And I think from overall,from a public health perspective,
(15:01):
reducing prior exposure to narcoticis something
big picture we should be aiming atbecause that's going to reduce,
I think, your need for narcoticif you need surgery.
But there are cultural differences.
And I think that evenwhen Matt was analyzing different sites
that the same NGO was visiting,
(15:22):
the amount of narcotic consumptionand prescription varied,
and that has to do with the population.
I think there is cultural differencesin terms of the interpretation
of pain,the tolerance for pain, the resilience.
I think some of it is embeddedin the culture.
Some of it is, you know,you have no choice but to be resilient
(15:45):
when you're living in an environmentthat's so harsh.
And I think people are extremely,
excited to get their hernias repaired.
And a lot of time,they're willing to tolerate, pain,
because the environmentthey live in is, often requires it.
And also they want to make surethat their recovery is happening smoothly.
(16:08):
So culturally,I think there's definitely a factor.
I think education and setting expectationearly on is another thing
we can learnand bring back to the US in terms of,
you know, what are our expectationfor pain control after a surgery
and what is what should be toleratedversus what you know should not exist.
And I think these are some of the thingswe've been discussing and talking about
(16:32):
as far as, you know, some of the lessons,
in pain toleranceand cultural differences.
Those are those are amazing, perspectives,
in the small amount of timethat we have left,
I did want to cover one additional thing.
So this is in the concluding paragraphof this amazing manuscript
that has been published in JACS,the statement, you say that “Our findings
(16:53):
suggest that even with national effortsto reduce
opioid prescriptions after surgerythrough educational initiatives,
prescribing guidelines and standardizedpatient instructions,
other changes urging the further attenuateof opioid prescriptions
in the US might be necessary.”What are your thoughts?
(17:14):
I mean,I think that there's prospective studies.
There's a lot of different thingsthat you can think about.
But where should we start?
Because we thought,okay, let's raise the awareness.
And through an educational initiativethat should change the thing.
Probably a little bit of behaviormodification.
Not a lot.
We thought that publishingthese guidelines, that should
(17:34):
certainly lead to changeand that didn't do it.
And then, as you correctly pointed out,you had standardized patient instructions
and that didn't do it.So I guess what's next?
I mean, is it bundles of therapy?
Is it,you know, rolling into another program?
I'm just curiousas to where you think we should go next.
Yeah, I think Tom, you point to the fact
that this is a complex,multifactorial problem.
(17:57):
There isn't one solutionthat fits all the issues.
I believe there's, articlecoming up in JACS next month
that talks about opioid stewardship,
by Dr Alexa Melucci.
She's the first author,and I think they have a, you know,
stewardship program that has resultedin significant reduction in their use.
(18:18):
But I think, you know, the solutions,
that have
partially shown some effect: awareness, education, guidelines, (18:23):
undefined
have been out there,but I think we need a better solution.
I think that,
reducing the exposure, with,
increasing the non-opioid interventionis something we haven't worked on enough.
And there's something of a gapwe see when we compare our use
(18:46):
compare here in Newark compared to LMIC,we need to decrease
not only narcotic but we use alternativemethods non-opioid options
whether it's ice or NSAIDsor others, Gaba, etc.
to kind of manage the painin a way to avoid opioids.
Amazing.
(19:07):
You know,I think that, obviously I’m biased
I mean, we love seeing this publishedin JACS, but I think that really I'm
hoping that this is the startof a continuing conversation.
So, and I don't in any way meanto minimize any of the efforts we've done
so far in terms of raising awarenessand the guidelines and the,
(19:28):
educational,you know, you know, patient instructions.
I just I think that this,this is a phenomenal study in terms of
doing a snapshot, aspect of where are we
right now and where do we need to go?
Dr Linz,since you you're the youngest amongst us.
I'll leave you with the final words.
Hopefully this has wet your appetite interms of doing this type of academic work.
(19:50):
And I'm hoping that you will continue towork with Dr Sifri for going forward. But,
any final comments to Dr Linz in termsof, your reflections on this project?
Yeah.
I think there's a lot of room forcontinued improvement in this space. And,
I look forward to
working with Dr Sifri and hopefullysome other collaborators too,
(20:11):
to continue, work in this effort
to reduce opioids after surgery.
Well, on behalf of all of our incredible,
loyal listeners here at the Journalof the American College of Surgeons.
Dr Linz, Dr Sifri.
Thank you for doing this, incredible work.
Thank you for all your effortsin global surgery and, you know,
(20:33):
improving care for all of our patientsaround the world.
And, on behalf of all of us, gratefulthat you were willing
to share this workand get it published into JACS.
Thanks for sharing your time with ustoday.
Thank you for listening
to the Journal of the American Collegeof Surgeons Operative Word Podcast.
(20:54):
If you enjoyed today's episode,spread the word on social media
by using the hashtag #JACSOperativeWord.
Subscribe to the operative wordwherever podcasts are available,
or listen on the American Collegeof Surgeons website at FACS.org/podcast.
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