Throw Away the Script

Becoming an opioid-sparing surgeon was the most liberating thing I've done in 25 years of practice. Why? Because before I started down this revolutionary path, I'd unwittingly become a pain-management specialist. True, I was an orthopedic surgeon and a healer — what I wanted to be — but I was also writing prescriptions for narcotics. And I was writing refills. And I was spending time trying to wean patients off their medications, because 20% were popping them like Jujubes — very early on showing signs of dependence, abuse and addiction. Plus, I was getting calls at all hours of the day and night, and had to be concerned about patients calling me on weekends.

Not anymore. Now, 5 years later, I'm still a healer of knees and shoulders, left and right, but that's it. Not because I don't care about my patients. I care deeply about them. But because, thankfully, we've figured out how to manage and minimize pain, so that they — and I — no longer have to worry about whether opioids might ruin their lives.

It's important to remember just how this profound and deadly opioid crisis came about — how it is that 4 out of 5 heroin users started with prescriptive opioid medications.

It happened because we succumbed to misinformation and an absurd proposition. The misinformation we were fed was that opioids are inexpensive and non-addictive. Both of those assertions turn out to be patently false. The absurd proposition was that we could and should consider pain a vital sign, and that we had to make sure our patients were completely pain-free. We were told, in fact, we would be graded on our work. Pain would be quantified on a 1 to 10 scale, and if our patients weren't zeros or ones, our hospitals could be penalized and our satisfaction ratings would surely plummet.

And yet we all knew that the notion that pain is objective and measurable is ridiculous. We can objectively measure blood pressure, pulse rate and oxygen saturation. But pain is subjective. One patient's 3 is another patient's 5, or 7 or "worst pain of my life."

And as for opioids being cheap and safe, little could be further from the truth. They're highly addictive. Twenty percent of patients who complete a 10-day course of opioids begin to show signs of addiction. And though they may be cheap up front, once you consider the loss of life, the economic impact of substance-abuse disorder and the cost of managing addiction, they're tremendously expensive to society — much more expensive than the alternatives.

Fortunately, times are changing. I used to feel like a lonely voice in this battle. Now, there's a large cadre of opioid-sparing surgeons who are more than willing to have this essential conversation. And every day, more surgeons are converting.

Now for the slightly controversial part of my story. In addition to becoming aware of breakthroughs in multimodal pain regimens — combinations of non-opioid medications that target specific pain pathways — the turning point for me came when my partner, David Prybyla, MD, told me about a journal article he'd read on liposomal bupivacaine. (He reads a lot more than I do.)

I know what you're thinking. And it's true. Liposomal bupivacaine (Exparel) has become the licorice — or maybe Grateful Dead — of the medical world. You either love it or you hate it. I'm keenly aware that of the thousand or so journal articles that have been written about it, roughly 500 are pro and 500 are con.

Here's my view: I think of it as more a medical device than a pharmacologic process. In other words, you have to use it the right way or you won't get the results and outcomes you want.

What's the wrong way? The first mistake surgeons make with Exparel is not using enough. You have to infuse the entire surgical area, or the liposomes won't reach all the nerves that have been injured. The second mistake they make is not putting it in all the right places. For example, with total knee replacements, you absolutely have to inject the posterior capsule. In many of the "con" papers I've seen, the researchers failed to do that. If you inject it everywhere else but miss the posterior capsule, you might as well not bother, because the posterior capsule is really going to hurt.

The point is, there are about 5 million liposomes in a 20-cc vial, but they don't know where to go; they only know what to do. They'll only work if you put them into all the right places. You have to mix the medication to a volume that lets you get to where you need to go.

Admittedly, the company that markets liposomal bupivacaine (Pacira Pharmaceuticals) is partly to blame for some of the early failures. They were a new company with one product, and, in retrospect, they could have done a better job of conveying a clear message and clear instructions.

Ultimately, Dr. Prybyla and I used trial and error to figure out the where and the how much. For a total knee, is 40 cc's enough? How about 60 cc's? It turns out that 120 cc's is the right volume for a total knee. We use 20 cc's of Exparel, 20 cc's of Marcaine 0.25%, and 80 cc's of saline. Again, you have to make sure the liposomes reach every area and nerve that has been injured.

These days, when I'm giving talks about opioid-sparing techniques, I know at least one person in the audience is going to come up afterward clutching an article that says liposomal bupivacaine doesn't work — and that's why they don't use it. I say, great, let's read the article together, really get into the nuts and bolts of it, and I guarantee I'll be able to show you exactly why it didn't work the way it was supposed to.

Of course, as I mentioned, there's more to opioid-sparing surgery than just liposomal bupivacaine. Pre-operatively, we work with anesthesia providers and administer a multimodal cocktail that includes a standard dose of IV Tylenol (Ofirmev) and 200 mg of Celebrex.

Post-operatively, I write a prescription for Tylenol 1000 mg po q8. Writing the prescription is important, because we don't want patients to think it's just an elective. We also use the NSAID Meloxicam 15 mg po qd, because it doesn't require pre-authorization, and Gabapentin 300 mg po qhs, which is to be taken only at night. The reason: It helps with sleep, and it manages pain in a different pathway. Patients take each medication for 5 days.

Clear understanding of the protocol is essential, of course, so we go over it post-operatively with patients so many times that by the time they're ready to leave, they can tell the next patient what the protocol is. And of course, if needed, we use interpreters or explain everything to family members. Finally, we call patients the day after they get home and review the protocol one last time.

Which brings up another important point: Patients have to understand that it's OK to have some pain after surgery, that they should expect it (see "Pre-op Conversation Sets Tone for Opioid-sparing Surgery"). When I consent patients in my office, I tell them my expectations about pain management, and I tell them I want to hear theirs. I explain that I don't expect them to be pain-free, but I do expect to get them to where they're comfortable.

Almost invariably, they're relieved by that conversation. Because nearly everybody knows somebody — a brother or a friend or a colleague — who's had a problem with opioids. Bottom line: To be a successful opioid-sparing physician, you must have that conversation with your patients.