Smart and Safe Opioid-Sparing Surgery

Education, multimodal pain management and continuous research create ‘little miracles’ every day.

About a decade ago, Michael P. Ast, MD, performed a hip replacement surgery on a 40-year-old male, a procedure he’d done many times before. “I thought everything went great. Everything was straightforward, and for all intents and purposes, it was a successful surgery,” says Dr. Ast, vice chair of the HSS Innovation Institute and chief medical innovation officer at Hospital for Special Surgery (HSS) in New York City.

The underlying issue

Despite Dr. Ast’s assessment, his patient still wound up in the ER several times after the procedure because of his post-op pain.

What happened? While the result of Dr. Ast’s surgery was technically successful, his patient had undergone a series of hip surgeries in the past. Those procedures — and the subsequent generous opioid prescriptions the patient received after discharge — had a cumulative effect. By the time he’d gone to see Dr. Ast, the patient had quietly developed a true opioid addiction from all his previous surgeries, and he didn’t even know it. Neither did his providers. “I didn’t recognize it, the people around us didn’t recognize it, and it created a very miserable experience for what should have been a very successful hip replacement,” says Dr. Ast. Once the problem was recognized, the patient’s providers were able to treat the underlying condition and get him back to doing everything he wanted to do, and everything worked out. But the case was a turning point for Dr. Ast, who is a strong proponent and practitioner of opioid-sparing surgery.

• Educate on expectations. For Dr. Ast, a successful opioid-sparing surgery regimen comes down to three key elements: patient education, multimodal pain management and a focus on continuous research into new and novel ways to treat patients. “Above all else, I think the education is critical,” he says. “Providers need to have a fundamental understanding of the education involved in pain after surgery, of helping set appropriate patient expectations.” When you are trying to minimize the use of opioids, you need patients to understand that surgeries — especially orthopedic knee and shoulder replacements — tend to be quite painful, and some pain is expected and appropriate. Patients, says Dr. Ast, need to understand the goal is to keep them at a level of pain that is tolerable and that providers will do everything they can to maintain that level — but that doesn’t necessarily mean “pain-free” all the time.

The good news is today’s patients tend to be well-educated on the dangers of opioids — often to the opposite extreme. “Some patients will say, ‘Oh my gosh, I don’t want to take any opioids, I’m going to get addicted,’ ” says Dr. Ast. “I’m all about avoiding addiction, but opioids do work for certain types of acute pain.” In these cases, providers need to focus on appropriate opioid usage. “Sometimes I’ll need to tell patients, ‘It’s OK to take one or two of these in really bad situations as a rescue medication,” he says.

• Make multimodal work for you. Kathleen Roman, MD, perioperative service line director and chair of anesthesia at UCHealth Yampa Valley Medical Center in Steamboat Springs, Colo., views opioid-sparing surgery as something that’s synonymous with multimodal analgesia. “Multimodal means combining an array of analgesics to achieve pain control with a minimal amount of opioids,” she says. “There are so many different medications that we can use here that it can seem overwhelming to providers, but once you start to incorporate various combinations you see how easy it can be to decrease or even eliminate opioids altogether.” Dr. Roman cites everything from Tylenol, NSAIDs and gabapentin to lidocaine, dexamethasone, cortico-steroids and sometimes even ketamine as useful multimodal analgesics in the outpatient setting.

Education-wise, nurses at UCHealth work hard to drive home exactly what the aim of multimodal is. “What’s explained to the patient is that we don’t expect Tylenol or NSAIDs to completely cover your pain, but these medications each target a different receptor or area that, combined together, will decrease your pain so that you’ll need the least amount of potent opioids possible,” says Dr. Roman.

TED TALKS

Dr. Scott Sigman Presented His Painkiller-Preventing Philosophy at TEDxDavenport

BRIGHT LIGHTS Dr. Scott Sigman gives his presentation “Changing the Paradigm of Pain Management” at TEDxDavenport.

For years, Scott Sigman, MD, has preached the gospel of opioid-sparing surgery and has long been recognized as a nationally and internationally recognized leader in that space. Recently, Dr. Sigman — who practices at the Lowell (Mass.) General Hospital Surgery Center at Drum and hosts “The Ortho Show” podcast — was given a tremendous opportunity to take his opioid-sparing message to the next level by recording a presentation at the TEDxDavenport event, an independently organized TED (Technology, Entertainment, Design) talk. Dr. Sigman described his TED talk — titled “Changing the Paradigm of Pain Management” — as “a mea culpa for surgeons who were duped by big pharma about the concept that opioids were inexpensive and non-addicting when it’s actually the exact opposite. They are incredibly addictive, and we just didn’t know. The talk is about the journey of moving away from addictive opioids to alternative solutions for our patients so that they can safely and effectively undergo surgery and not worry about becoming addicted to opioids.”
—Jared Bilski

A multimodal approach is key to Dr. Ast’s opioid-sparing regimen, as well. For instance, in total knee cases, the process begins by premedicating patients with Tylenol and some type of anti-inflammatory, followed by spinal or epidural anesthesia combined with adductor canal and iPACK blocks. Most total knee replacements also receive a periarticular injection or injection of local anesthesia directly into the surgical field. “This is something we’ve been doing at HSS since the ’90s,” says Dr. Ast. “We were one of the pioneers of that concept with Dr. Chitranjan Ranawat.” For sedation, Dr. Ast and his team use propofol and often a bit of ketamine as well as intraoperative IV steroids in appropriate patients. Postoperatively, patients are sent home on Tylenol, an anti-inflammatory and a breakthrough narcotic. Dr. Ast has also incorporated newer modalities such as intraoperative acupuncture in certain patients — and the results have been staggering. “We’ve seen 60% decreases in opioid use over 90 days with a single episode of intraoperative acupuncture,” he says. “I would doubt the data on this if it weren’t my patients.”

From an anesthesiologist’s standpoint, regional anesthesia is a vital piece of the opioid-sparing puzzle. It’s a technique Dr. Roman has employed ever since going into practice for notoriously painful cases like total shoulder replacements. Dr. Roman’s patients receive an ultrasound-guided interscalene block preoperatively to bathe the nerves around the shoulder with long-acting numbing medications such as bupivacaine or ropivacaine for maximum relief. “Generally, we infiltrate anywhere from 15 to 30 mLs of local anesthetic, and it takes 10 to 20 minutes to take effect, depending on which medication we use,” she says. That approach tends to cover every area in which the surgeon operates and provides numbness for anywhere from 18 to 24 hours postoperatively. Long-acting locals such as liposomal bupivacaine can extend that time-frame even longer, up to 72 hours in extreme cases. “Over the past 10 years, there’s really only been a handful of shoulder cases where I used any opioids,” says Dr. Roman.

• Push the pathway forward. As the practice of opioid-sparing surgery continues to evolve, it’s up to providers to keep pace with the improvements in technique and innovations in technology.

That means staying abreast of the latest research and incorporating new approaches whenever possible. “If, as a facility or service line, you truly want to continue to push the pathway forward on minimizing opioids after surgery, then you must do research on new, novel and thoughtful ways to improve patients’ ability to recover from surgery comfortably and successfully,” says Dr. Ast, adding that this research doesn’t need to involve complex projects with large-scale randomized trials and publishing peer-reviewed articles. “Many providers aren’t equipped with the infrastructure to do formal research,” he says. “That doesn’t mean they can’t learn from the others and implement those findings into their own workflow and patient populations.” It could be as simple as reaching out to peers about what they’ve done. For instance, Dr. Ast says when HSS put out a press release for a brand-new (non-FDA-approved) medication that was a combination of oral ketamine and aspirin, his peers reached out to him directly. “Immediately, five of my colleagues from all over the country sent me messages asking about it,” he says.

No reason not to

If facilities can safely and effectively perform surgeries with minimal narcotics, don’t they owe that to patients? For Dr. Roman, the benefits of opioid-sparing surgery — made possible in part because of the right multimodal approach — are well worth the extra effort required. “I can think of so many patients who have been helped by this, patients who have histories of opioid-use disorders and have come in just terrified to have surgery because they don’t want to start up the problem,” she says. “As a caregiver, any time you can decrease a patient’s anxiety, ease their pain and help them keep their quality of life, it’s like a little miracle.” OSM