Opioid Sparring Surgery
Opioids during my medical training were described as inexpensive and minimally addictive. That could not be any further from the truth. The reality is that Opioids are highly addictive and are incredibly expensive to our society. A recent CDC analysis demonstrated that of the patients given a 24-hour prescription of narcotics, 6% were still on narcotics at one year. If given a 10-day supply, 13% were still on opioids at one year, and if given a 30-day supply 30% were still on opioids at one year. Opioids should be minimized for post-surgical pain.
The good news is we have excellent alternative solutions to manage post-operative pain while minimizing Opioids. Multi-modal pain programs and Enhance Recovery after surgery (ERAS) protocols have helped to dramatically reduce the need for narcotics. With the use of long acting anesthetics, regional nerve blocks, and improved non addictive pain medication options we have been able to change the paradigm of post-operative pain management. I strongly recommend to all patients to seek out healthcare providers and healthcare systems that are following Opioid Sparing techniques and protocols.
My approach to opioid sparring surgery
Communication is paramount when establishing an Opioid sparing strategy. Communication with our patients about their pain management occurs in the office when the patient is consented for surgery, and all throughout the surgical experience. It is vital to make sure that all members of the preoperative team are providing the same messaging. We want our patients to know that we will be addressing their post-operative pain with multiple modalities to minimize the harmful addictive effects of Opioids.
Preoperatively we have eliminated long acting opioids from our regimen. Instead we provide Celebrex 200 mg and a dose of IV Tylenol.
All of our upper extremity surgical patients now receive a liposomal bupivicaine scalene regional block done under ultrasound (US). If the patient has a history of COPD or other major pulmonary issue, we will pivot to an US guided suprascapular and axillary nerve block also performed via US by our anesthesiologist. Motor block usually lasts 24 hours, sensory up to 36, and analgesic effects out to 5 days. This has revolutionized shoulder replacement and rotator cuff surgery. The vast majority of our upper extremity surgical patients are Opioid free.
For knee replacements (TKR), we perform a short acting spinal with local infiltration/surgical field block during the procedure with liposomal bupivicaine. The technique is available on www.exparel.com. Alternatively, anesthesia can perform an adductor, IPAC block with good effect. In addition, we have been using IOVERA, a cryo-axonomesis device one week prior to surgery. This provides a temporary cutaneous nerve block for 90 days that helps patients recover faster. Most of our knee replacements are off all medication within 5 days.
For our patients undergoing ACL reconstructions and osteotomies a liposomal bupivicaine field block has worked exceptionally well. 95% of our ACL patients are now opioid free. This technique is also available on www.exparel.com.
Our post-operative pain regimen is very specific. We provide four prescriptions for each patient.
- Tylenol 1000 mg po q8 for 5 days. We write an actual prescription. We want to ensure the patient understands this is an important pain reliever.
- Meloxicam 15 mg po qd for 5 days. We use Meloxicam instead of celebrex because it does not require prior authorization.
- Gabapentin 300 mg po qhs for 5 days. This helps with sleep and pain relief.
- OXY IR 5 mg total of 5 tablets. We encourage our patients not to take this but provided it as a backup.
Becoming an Opioid sparing surgeon is the most liberating thing you can do in practice. There are no more requests for prescription refills and no need for the weaning process for the patients that have become inadvertently addicted. Fortunately, the paradigm of post operative pain management has shifted away from harmful Opioids.
About the author:
Dr. Sigman is a national and internationally recognized leader in Opioid Sparing Surgery. He is an Orthopedic Surgeon that specializes in the knee and shoulder. He has been in clinical practice for over 25 years and is a leader in professional education, medical device development, and has numerous peer reviewed publications. He is the team physician at UMASS Lowell. He is a member of Governor Bakers Commission to establish a pain management access program in the Commonwealth of Massachusetts.
He did his sports medicine fellowship at the prestigious Kerlan Jobe Clinic in Los Angeles. His Opioid Sparing leadership propelled him to become a Fellow of the Worlds Society on Sports and Exercise Medicine, and most recently has had the honor of becoming a Fellow of the Royal College of Surgeons in Ireland.
In addition, to his clinical responsibilities Dr. Sigman is the Chief Medical Officer for OrthoLazer Orthopedic Laser Centers. The OrthoLazer franchise was developed to provide an alternative treatment option for acute and chronic pain to help combat the Opioid crisis. Dr. Sigman is also the host of the popular The Ortho Show podcast.