REALISTIC APPROACH Get patients on their outpatient pain regimen as quickly as possible and set reasonable expectations about the discomfort they'll feel.

Pain. It's what patients are likely to remember most about their surgery, regardless of how many times your nurses smiled or how successful the surgical outcome. What can you do to manage the fifth vital sign, so patients are ready for a timely discharge and return to normal life routines as quickly as possible? We chatted with a few of the nation's leading pain experts to find out.

Leading pain management experts open up about why opioids are still overused, the most difficult patients they treat and what analgesic regimens might look like in the not-so-distant future.

Eugene R. Viscusi, MD
Director of Acute Pain Management
Thomas Jefferson University
Philadelphia, Pa.

John Stamatos, MD
Director of Pain Management
North American Partners in Anesthesia
Melville, N.Y.

Mark Snyder, MD
Director of the Orthopaedic Center of Excellence
Good Samaritan Hospital
Cincinnati, Ohio

Philip Wagner, MD
Co-Director of Acute Pain Services
Hospital for Special Surgery
New York, N.Y.

Are surgeons and anesthesia providers becoming more nuanced in their approach to treating pain?

John Stamatos, MD Without question. We've become more specialized and gotten more comfortable with what we have in our armamentarium of pain-relieving tools. Preemptive analgesia is still the basis for everything. Once someone has pain, it's very difficult to treat. Preventing pain from happening is best practice. By the time patients get to recovery, there's less need for narcotics.

Length of stay and patient satisfaction are the buzzwords in every facility setting. Ignoring the importance of controlling pain puts patients at risk for longer stays and decreased satisfaction. Pain management is absolutely associated with how patients feel about their surgery. Without question, you need to address it. Spending a little more money on the medications to do it right pays off in the long run, because patient satisfaction increases.

Eugene R. Viscusi, MD But we're in a volume-driven specialty and we're definitely in a cost-minimization era of health care where any extra dollar spent has to have a profound effect on patient care. And that's not only based on independent data. Many centers now demand that they see benefits with their own patients before supporting the additional cost for some pain control agents.

What are the pillars of your multi-modal regimens?

Dr. Viscusi Acetaminophen, whether administered PO or through an IV (Ofirmev), is probably the most well-tolerated analgesic we have at our disposal. The majority of patients can tolerate it, except perhaps individuals with advanced liver disease. Used at appropriate doses as an around-the-clock pain-relieving drug, it has been shown to markedly reduce opioid requirements.

Dr. Stamatos IV acetaminophen is just wonderful. It works as a great adjunct medication and as a narcotic-sparing drug.

Dr. Viscusi Steroids are used commonly in the outpatient arena, but might not be fully understood for what they do. Many anesthesia providers give a healthy dose of dexamethasone (Decadron), which is a wonderful antiemetic and anti-inflammatory agent that contributes to better pain management.

Philip Wagner, MD We've found a very good pain management protocol for hip and knee replacement patients that gets them out of bed the next morning: a spinal or epidural anesthetic followed by a transition to oral medications, which involves a combination of an anti-inflammatory adjunctive medication such as pregabalin (Lyrica) or gabapentin (Neurontin) and some level of opioid medications for patients who need stronger pain relief during the transition off the initial cocktail.

Dr. Viscusi Nonsteroidals and COX-2 inhibitors are anti-inflammatories that work peripherally and centrally. The beauty of the peripheral action is that it's very effective for dynamic or movement pain.

Dr. Stamatos Ketorolac tromethamine (Toradol) is still the mainstay of IV nonsteroidal agents. It's been around for 15 years and is still very effective. The initial studies when the drug first came out said a single dose is equivalent to 3 mg of morphine for attacking bony pain. For an anti-inflammatory to have that kind of pain-relieving potential is pretty good.

Dr. Viscusi Post-op pain is a mixed pain syndrome. We're mistakenly told to think of it as nociceptive pain alone, but the reality is that many patients have burning pain with characteristics of what you'd describe as neuropathic signaling. Gabapentinoids, which are antineuropathic agents, are extremely effective when there is a high incidence of burning pain. Even in the absence of neuropathic pain, they seem to have analgesic properties of their own and reduce opioid requirements.

LEAD BLOCK Using regional anesthesia to limit initial pain is a key to sending patients home the day of surgery.

What role do regional blocks and local anesthetics play in your protocols?

Dr. Wagner Our strategy is to use nerve blocks for most patients undergoing outpatient surgery. We're able to give them pain relief that will last 8 to 48 hours, which gets them through a period of severe pain without the need for other analgesic medications. Using nerve blocks to limit that initial pain is one of our strategies to get people home the day of surgery. But blocks wear off, so you need to give patients the resources they need to stay comfortable.

Dr. Stamatos A bupivacaine liposome injectable suspension (Exparel) is the first generation of a single-shot, extended-release local anesthetic, and it's absolutely where pain control is heading.

Dr. Viscusi Exparel is touted to provide up to 72 hours of local anesthetic delivery. With a single injection, you get a local anesthetic effect for an extended period of time, hopefully eliminating the need for a catheter delivery of local anesthetic. Sometime this year, we hope to see its indication expanded for use in continuous peripheral nerve blocks.

Mark Snyder, MD In our independent, prospective, double-blinded, randomized study of 70 knee replacement patients, half of the patients received Exparel instead of a continuous nerve block. We initiated the preemption of pain with a spinal anesthetic and injected Exparel into the posterior capsule before the implant was centered, and also into the deep capsule, collateral ligaments and deep fascia. We then added 30 cc of 0.5% bupivacaine to the subcutaneous and dermis areas as a bridge injection because it takes 3 to 4 hours for Exparel to bathe tissue with its bupivacaine effect. Results with Exparel were statistically better in terms of patient reported pain levels, morphine equivalent consumption, length of post-op stay, adverse events and fall rate — patients who received Exparel experienced better results across the board.

Dr. Viscusi There's still a lot to be determined about Exparel's expanded use. There's no question that pumps and catheters are a burden of care and an added expense, and there are risks associated with any kind of indwelling pump and catheter assembly, but you have to look at these options as a risk-benefit ratio. Continuous catheters provide fairly targeted local anesthetic administration for the duration of the time the catheter is placed. The beauty of Exparel is that it's easier to administer a single injection than it is to place a catheter. But we have to see if Exparel stands up to what a catheter delivery system provides. Is it more reliable to do a single injection? Yes, but we don't yet have head-to-head data. I hope that Exparel will find its niche for extended duration peripheral nerve blocks, but we're still in a wait-and-see phase.

Dr. Wagner We're working with other medications, such as clonidine or dexamethasone, to extend the duration of local anesthetics. Interestingly, patients who receive a block that lasts 2 or 3 days often express dissatisfaction with having their joints numbed. After about 24 hours, some patients say they'd rather experience the pain than deal with the numbness.

OPEN DIALOGUE Discuss pain control options with patients so they're aware of the reasons behind your methods.

Simply reducing the use of opioids is an attainable and valuable goal. Is there too much stock put in opioid-free analgesia? Do caregivers lose focus on the benefits of at least reducing narcotic use?

Dr. Snyder Most physicians still believe that narcotics are the go-to drugs for pain. They're also the first to admit that there are major problems with using opioids. Patients can have serious side effects and are at high risk for drug tolerance, and maybe even addiction.

Dr. Wagner I work in a high-volume orthopedic hospital — we do about 20,000 joint replacements a year and 39,000 total procedures annually, everything from complex spine reconstruction to outpatient bunion surgeries and everything in between — so patients have severe pain when they go home. Opioids are still the primary treatment modality for severe pain. We haven't found a complete substitute. We'd like to, but we haven't yet.

Dr. Stamatos Opioids are there to kill pain. The other side of the coin is abuse. It's a wonderful thing if you can get away from using narcotics. But to say we're going to do this opioid-free isn't a reasonable goal. Shoot for getting down to the minimal amount, and doing everything you can to stay away from that class of medications.

Dr. Viscusi We do need to think about the amount of opioids prescribed that aren't warranted, that collect in home medicine cabinets, where they're available for abuse and diversion. Opioids prescribed without clear indication contribute to the well of drugs that aren't consumed, which is now a recognized problem. So the issue is complicated, and it takes a lot of effort. You see clear benefits in reducing the use of opioids, but trying to prove those benefits to caregivers and patients can be challenging.

Dr. Wagner Patients expect their pain to be managed. They don't expect opioids, although there are plenty of people who say they'd rather avoid them, if possible. Most patients expect they'll take Vicodin and Percocet for some period after surgery, but most also expect to limit the amount of time they're on those medications.

Dr. Viscusi The average patient isn't fully aware of the available options. It's unusual for a patient to request a regional block, a catheter and home infusion delivery system or the newest drug. If anything, patients and providers are still opioid-oriented, without being aware of the ultimate risk to the individual and society. While we're making great strides at reducing the amount of opioids used, many patients still expect to receive them. When you tell them they're not going to get their big bottle of oxycodone, they're hesitant and unwilling to accept that non-opioid alternatives may work just as well.

Dr. Wagner There are alternatives, but in the orthopedic setting, opioids are still a mainstay. We do a lot of regional anesthesia here, but that's not a complete substitute for opioids. Regional blocks get patients through a period of time when the pain is most severe, but most end up taking some narcotics.

Dr. Viscusi The threshold surgeons use to prescribe opioids is usually pretty low. Much of what they do is based on patient satisfaction, and if patients expect opioids, that's the easiest path to take.

Dr. Stamatos Individuals on chronic pain medications are some of the most difficult to manage. Being proactive with these patients is important. Ketamine infusions help to knock down the pain in chronic opioid users. It's not a new concept, but a lot of centers are making the old new again and giving ketamine to narcotic users coming in for surgery.

Dr. Wagner Ketamine temporarily reverses the tolerance that patients have to opioid medications. It makes additional opioid doses more effective and is a very good adjunctive non-narcotic medication that can be used to replace, to some extent, the effect of opioids. We use it intraoperatively and run infusions post-operatively for a day or so.

Dr. Viscusi It really is incredibly useful and effective in patients with opioid tolerance. You may use a bolus administration or bolus plus infusion. It's generally very well tolerated and has a clear impact on post-op pain.

DIGGING DEEP Knee procedures are notorious for leaving patients in significant post-op pain.

How do you envision pain management evolving in the coming years?

Dr. Snyder We know surgery causes pain, but what really causes it? How does pain move up and down the patient's nervous system from the point of surgery to the brain, and what medicine can be used to mitigate that? Those are questions to explore.

Dr. Wagner The Holy Grail is to provide pain relief without blocking patients' strength, to give them a pain sensory block while leaving them with intact sensation. It'd be great to separate pain relief from the euphoric, addictive and tolerant aspects of opioids — to get the effects without the side effects.

Dr. Snyder When the FDA allows it, we hope to conduct research on combining tissue injections with adductor blocks, which would result in soft tissue envelope control and more predicable pain management. Exparel is good standing alone in most patients if it's used properly. Injection technique might not matter, but the size of the surgery and patient selection are important. So is the current role of the preemptive regional anesthesia technique.

Dr. Wagner Hopefully we achieve a better understanding of the neurobiology of pain. There are drugs in the pipeline that modify the neural pathways of pain without involving opioid medications. A better understanding of how the spinal cord processes pain will lead to specific targets for drugs that work at the spinal cord level. That's on the 10-year horizon.

Dr. Viscusi I hope to see new products that are easier to use and more cost-effective. We may see the emergence of opioids that have fewer side effects than the current options. We may see other extended duration local anesthetics with unique profiles. I'm hoping we'll see new options among the NSAIDs. IV diclo-fenac was recently approved and the available information looks promising.

Dr. Stamatos Neuromodulation in some form will be the next big jump in pain control — figuring out a way to shut off pain input through the spinal cord with non-medical means.