Post-op Pain Pearls

If your anesthesia providers rely on inhaled anesthetics and opioids, they're behind the times. As Gary Lawson, MD, says: "I used to knock out patients. Now I knock out nerves." His email is [email protected], but Dr. Lawson, chief anesthesiologist of the Surgery Center of Naples (Fla.), has all but hung up his mask. He prefers to do his cases under regional anesthesia, which often obviates the need for opioids.

"We will knock out any part of the body that we can as opposed to general. That's what we like to do and we've trained all our providers to do," says Dr. Lawson, president of Quantum Anesthesia, which places 10 CRNAs and 5 physician-anesthesiologists throughout Florida.

The maxim — general never fails but regional is iffy — no longer holds true, says Dr. Lawson. It helps that he no longer relies on anatomical landmarks and patient cooperation to place blocks. Now he places blocks with the precision of dual guidance: nerve stimulation and high-resolution ultrasound.

For orthopedic cases, his go-to anesthetic consists of motor-sparing peripheral nerve blocks, such as the iPACK (interspaced between the popliteal artery and the capsule of the posterior knee) and adductor canal block, as well as oral diclofenac, gabapentin and acetaminophen.

For abdominal cases, it's oral diclofenac, gabapentin and acetaminophen, as well as a TAP (transverse abdominis plane) block. The TAP block was initially used for such lower abdominal surgeries as prostatectomies and hysterectomies, but providers are now applying it to other locations, including the upper abdomen for patients who have laparoscopic cholecystectomy or other upper abdominal minimally invasive procedures.

"You have to try to find and promote techniques that not only have clinical benefits, but are also fairly easy for providers to perform. Otherwise, it's difficult to get them to the point to apply them consistently," says Ed Mariano, MD, MAS, chief of anesthesiology and perioperative care at the Veterans Affairs Palo Alto (Calif.) Health Care System.

These days, you can't discuss post-surgical pain management without first talking about the opioid crisis. Few would disagree that opioid-sparing pain relief is desperately needed, so how is it that from 2010 to 2016, surgeons have written 18% more new opioid prescriptions, while primary care physicians have been writing fewer opioid scripts over the last several years, according to a study (osmag.net/dyCN5M) Some would say that surgeons would like to change their prescribing practices, but they're slow to adopt opioid-sparing strategies and they still believe that opioids have a role to play in mitigating pain.

You might point providers who are on the fence about opioid-sparing surgery to a study conducted by University of Michigan researchers, who wanted to find out if an opioid-sparing strategy would be feasible for patients undergoing 6 different procedures at their institution: laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, thyroidectomy/parathyroidectomy, robotic prostatectomy, endoscopic sinus operations and laparoscopic sleeve gastrectomy. More than half of the patients used no opioids after their operations, and almost all of the patients reported their pain was manageable, according to the findings (osmag.net/bh4YSN).

The research team's work is motivated by the fact that many people not taking opioids before their operations ("opioid-na??ve") become new chronic opioid users after their operations, says Michael Englesbe, MD, FACS, the study's corresponding author and a professor of surgery at the University of Michigan in Ann Arbor.

"We think a fundamental root cause of the opioid epidemic is opioid-na??ve patients getting exposed to opioids and then really struggling to stop taking them post-operatively, and then moving on to chronic opioid use, abuse, addiction and overdose," says Dr. Englesbe.

The researchers enrolled 190 opioid-na??ve patients. Participants received specific instructions regarding post-op pain control, pain expectations and counseling to learn to manage pain without opioids. At their pre-op clinic visits, patients were instructed to take acetaminophen or ibuprofen every 6 hours around the clock, and to stagger these medications every 3 hours for maximum continuous pain control.

After their surgeries, patients received prescriptions for 650 mg of acetaminophen and 600 mg of ibuprofen, as well as a small "rescue" prescription of opioids — mostly oxycodone — for uncontrolled breakthrough pain. For example, laparoscopic cholecystectomy patients were prescribed 4 oxycodone pills. Patients were instructed that they didn't have to use the opioids if they didn't feel they were needed.

Between 30 and 90 days after their operations, patients were asked to report the number of opioid pills they used post-operatively. More than half (52%) of patients used no opioids, and 98% used 10 pills or fewer. Among the 48% of patients who did use opioids, on average they used 4 pills, and had 2 leftover pills.

Almost all patients (91%) said their pain was manageable using this strategy. The median pain score for the whole cohort was 1, or minimal pain; that number was 2 for patients who used opioids. Overall, the median patient satisfaction score was 10 on a 10-point scale, or extremely satisfied, and the median quality of life score was 4 on a 5-point scale.

Dr. Englesbe notes that fewer opioids are only one component of the larger pain management strategy. The focus has to be on what does work, which will not be the same for every patient.

"Just not giving opioids is not the answer — we have to give the best pain care," says Dr. Englesbe. In the case of this study, the team provided a full care pathway. "From the beginning, everyone was on the same page with talking to patients about their ?pain ?and letting them know that operations hurt," adds Dr. Englesbe.

He and his team are just getting started. They will expand their list of selected surgical procedures from 6 to 18 and are working to implement the strategy to other institutions across the state.

"Our overall goal is to have half the operations done in the state of Michigan without patients needing opioids and still getting excellent pain care," says Dr. Englesbe. "There are alternatives to opioids for surgical pain that work well and we should be using them more." OSM