Opioids Are Overplayed

Anesthesia

By: Jared Bilski

Published: 10/14/2019

Share:

There are smarter, more effective ways to manage post-op pain.


How long has it been since you last heard about the importance of limiting the use of opioids to manage post-op pain. A few months since your last national conference? A few hours since meeting with your clinical team? A few seconds since reading this article's headline? Opioid-sparing surgery is all the rage, and with good reason. The very real risk of abuse and addiction, and the migration of more complex — and more painful — cases to outpatient ORs make a carefully structured multimodal regimen a virtual necessity if you want to provide cutting-edge patient care that's heavy on pain relief but light on opioids.

Beyond the buzzword

The phrase "multimodal pain management" has been thrown around often in recent years, so it's easy to lose track of what it actually means. From an outpatient perspective, a multimodal approach to analgesia can be boiled down to attacking pain with a combination of methods.

  • Interventional techniques, including spinal anesthesia and ultrasound-guided peripheral nerve blocks are among the most effective opioid-sparing analgesic tactics outpatient facilities have at their disposal.

"If there's an opportunity to do regional anesthesia for patients, we're going to take it," says Curtis Choice, MD, MS, director of anesthesiology at Montefiore Hutch-inson Metro ASC in the Bronx, N.Y.

And why shouldn't they? The effectiveness of regional blocks has grown exponentially thanks to advances in ultrasound guidance technology.

"Historic-ally, regional anesthesia was done almost blindly with a nerve stimulator," says Dr. Choice. "But nowadays, we can do a lot of these blocks safely and efficiently by going right at the nerves where the generation and propagation of the pain impulse occurs."

GOOD TALK Having anesthesia providers explain to patients everything they can expect post-op is a critical part of the education process.   |  Pamela Bevelhymer, RN, BSN, CNOR

With ultrasound guidance, the precision and safety of block placement are remarkable. Anesthesiologists can do everything from visualizing the brachial plexus and seeing the needle sheath to gradually giving a local anesthetic through hydrodissection. "You can see the nerves and blood vessels, so you have less incidence of issues like local anesthetic systemic toxicity," says Dr. Choice. "You have a greater safety profile because of the technology."

At Montefiore, surgeons perform numerous arthroscopic orthopedic procedures, and a significant amount of these are done with the aid of regional anesthesia. For example, shoulder arthroscopy patients receive interscalene brachial plexus blocks and, in some cases, a superficial cervical plexus block. For extremity procedures, anesthesia providers place supraclavicular brachial plexus blocks in combination with intercostobrachial nerve blocks.

  • Systemic pharmacological therapies. Multimodal drug therapies are built using core agents such as NSAIDS, alpha-agonists, NMDA receptor blockers, membrane stabilizers like pregabalin (Lyrica) and dexamethasone. The ultimate goal is to maximize the drugs' benefits for analgesia in the most opioid-sparing way possible, while also minimizing the risks that are inherent with the medications because, as Dr. Choice puts it, "Nothing's free — everything that we give also has some side effects."

When it comes to structuring your multimodal drug regimen, you need to balance what patients need for the smoothest possible post-op discharge with your own facility's pharmacological limitations. "Each facility has its own formulary and list of medications they will or won't carry, and providers are limited by that," says Dr. Choice.

In the end, it's the combination of drugs that wouldn't be nearly as effective on their own that makes the difference. "The reason we're giving all of these agents is to try and get as much analgesic control as we can while also minimizing or eliminating the administration of opioids," says Dr. Choice.

No more opioids?

Opioid-sparing techniques are far and away the most conventional school of thought in current pain control practices, but some providers insist you can do away with opioids altogether. Barry L. Friedberg, MD, a Newport Beach, Ca.-based anesthesiologist and the president and founder of the Goldilocks Foundation (goldilocksfoundation.org), a nonprofit that advocates for brain monitoring while patients are under anesthesia, has been practicing opioid-free anesthesia (OFA) since 1992.

The technique Dr. Friedberg developed and swears by — a combination of propofol-ketamine used in conjunction with real-time electromyography (EMG) and Bispectral Index (BIS) brain monitoring that measures hypnosis levels and the absence of EMG spikes — not only eliminates the need for opioids in the periop phase, it also greatly reduces the need in post-op and decreases the "brain fog" or post-op delirium that affects about 40% of patients. Plus, he says, it virtually eliminates PONV, which is a known side effect of opioids for many patients.

The problem, according to Dr. Friedberg, is the pain the patient experiences during the surgery itself. This pain is something that opioids don't address — at least not directly. "Opioids don't take pain away," says Dr. Friedberg. "They just make you not care about it."

Patients experience pain because of the invasive nature of surgery. "It sets off the 'wind-up phenomenon.' Patients wake up in pain because you hurt them while they were asleep."

COORDINATED CARE
The Keys to Limiting Opioid Use
MEETING OF THE MINDS Every member of the surgical team must be on board with your facility's pain management strategy.

Implementing an effective opioid-sparing regimen requires education and communication, for both your staff and your patients. Here are some simple ways to improve both:

  • In-services. At Montefiore Hutchinson Metro ASC in the Bronx, N.Y., anesthesiologists conduct frequent in-services for the nurses who work in the PACU. The sessions cover the various risks of opioid use and the types of questions they should be asking patients before they're discharged.
  • Provider briefings. Communication between surgeons and anesthesiologists is paramount, and both sides need to be on the same page. "The anesthesiologist needs to know the procedure's expected pain level, and the surgeon needs to know the modes of multimodal analgesia the anesthesiologist is using," says Gregory A. Liguori, MD, anesthesiologist-in-chief at the Hospital for Special Surgery in New York, N.Y. These briefings provide the opportunity for everyone to work together to create a reasonable, personalized prescription for post-op opioids.

"You can now tailor prescriptions to the procedure," says Dr. Liguori. "A knee arthroscopy may only need a few days' worth of pills. A rotator cuff repair of the shoulder, even with multimodal analgesia, is going to require more."

  • Discharge instructions. Because you can't directly monitor patients once they return home, often mere hours after surgery, you have to make sure they know exactly how to manage pain on their own. In addition to strategic pain management instructions (go around the clock with your NSAIDS to stay ahead of the pain, for example), the EMR at Montefiore Hutchinson Metro ASC is set to flag any patient who gets a nerve block, so they receive additional discharge instructions.

"The directions cover everything patients might encounter," says Curtis Choice, MD, MS, Montefiore's director of anesthesiology.

"It lets patients know things like when their block will wear off, say, at 2 a.m., and tells them not to be alarmed if they wake up in the morning with their arm still numb."

—Jared Bilski

A very specific combination of propofol and ketamine aims to eliminate surgical pain altogether, first by hypnosis and then by dissociation. The combination consists of a low, incremental dose of propofol 50 mcg/kg (titrated to BIS < 75 with a baseline EMG) followed by 50 mg of IV ketamine given 2 to 5 minutes before the incision and then a pre-incision subcutaneous injection of lidocaine with epinephrine, which Dr. Friedberg says acts faster than bupivacaine. The incremental propofol induction and maintenance protects against ketamine 's negative side effects.

The timing of the ketamine dose is key because failure to preemptively saturate the NMDA receptors causes the wind-up phenomenon, which eliminates the effectiveness of your opioid-free efforts to control post-op pain. Dr. Friedberg says giving the low dosage of ketamine in that 2- to 5-minute window doesn't merely "block" or close the door on the NMDA receptors, it slams that door shut. That 's how patients wake up pain free.

If you're skeptical about Dr. Friedberg 's method, he urges you to try one part of his analgesic cocktail. "Administer 50 mg of ketamine 3 minutes before the incision," he says, "and you'll see a dramatic improvement in your patients ' post-op [pain levels]." OSM

Related Articles