The self-proclaimed "opioid-sparing orthopedic surgeon" practices what he preaches. And, boy, does he preach what he practices.

"I have good news: Surgery does not require opioids," says Scott A. Sigman, MD, of Orthopedic Surgical Associates of Lowell (Mass.). "It has been an arduous journey, but I sense there is a paradigm shift occurring on the management of post-operative pain with opioid alternatives."

Dr. Sigman points to a patient who's 12 days out from her total knee replacement who hasn't required a single post-op narcotic pill. She has full knee extension and 115 degrees of knee flexion, he says. And she walked into Dr. Sigman's office for a post-op visit with a cane.

The woman had an Exparel (bupivacaine liposome injectable suspension) field block at the time of surgery and an iovera cryotherapy treatment 4 days before surgery. That's it? Pre-operative iovera cryotherapy treatment followed by intraoperative Exparel? Yes, says Dr. Sigman, that one-two punch gets almost all of his patients through the "storm of pain" that closes in the first 72 hours after surgery.

Cryotherapy is the latest technique Dr. Sigman has incorporated into his opioid-sparing knee surgery. iovera is a cryotherapy device — he calls it his "Freeze Ray Gun" — that temporarily freezes the axons of sensory nerves. The axons redevelop over 6 to 8 weeks after the stimulus of pain from surgery has resolved, says Dr. Sigman, who performs cryotherapy at his surgery center a few days before surgery followed by an Exparel field block at the time of surgery.

Exparel gives excellent initial pain relief followed by long-term pain relief from iovera, he says.

"We use saws and drills on a patient and it hurts like heck, but if you can get them to a softer landing through that first 3 days afterwards," he says, "the pain is not as bad as it was when it first happened because all of the chemicals that create that pain stimulus are washed out of the system."

Here are a few more opioid-sparing strategies you should consider:

Regional anesthesia

Brandon Winchester, MD, the regional anesthesia fellowship director at the Andrews Institute for Orthopedics & Sports Medicine in Gulf Breeze, Fla., gets pumped when he talks about managing post-op pain with regional nerve blocks, continuous catheters and pain pumps. He and his anesthesiology partner Gregory Hickman, MD, perform around 2,500 blocks a year. They know regional anesthesia has extensive benefits, including improved pain, decreased opioids, decreased nausea, shorter PACU stays and greater patient satisfaction.

For outpatient surgeries involving mild to moderate post-operative pain, such as wrist or ankle arthroscopies, a single-injection nerve block with bupivacaine or ropivacaine plus preservative-free dexamethasone will last 24 hours or longer. Patients usually are pain-free long enough to get back home and sleeping through the night the day of surgery and may start hitting functional milestones once they start PT, says Dr. Winchester.

For moderate to severely painful outpatient surgeries — total shoulder replacements, rotator cuff repairs, ACL reconstructions, knee replacements and ankle fusions — patients receive a continuous nerve catheter and disposable local anesthesia pain pump to provide 4 or more days of "excellent pain relief" with minimal to no opioid use, says Dr. Winchester. If their pain intensifies, patients can press the pump bolus button for a boost of local anesthetic.

An expanded use for Exparel

Rotator cuff surgery has about a 10% incidence of opioid reliance over time, studies show. That's why Dr. Sigman was so delighted when the FDA gave the green light last April to an expanded use for Exparel, which lets doctors use bupivacaine liposome as a regional interscalene brachial plexus block. That makes Exparel the first long-acting, single-dose nerve block available for patients undergoing upper extremity surgeries, such as rotator cuff repair and total shoulder arthroplasty. It relieves pain for 3, 4, even 5 days, says Dr. Sigman. "It provides a motor block for about 24 hours and a sensory block for about 36 hours," he adds.

Dr. Sigman touts Exparel's use as a local anesthetic and helped develop a protocol for ACL repairs. He divides a combination of 20 mL Exparel, 40 mL of normal saline and 20 mL of 0.25% bupivacaine HCI amongst 8 10-mL syringes with 22-gauge needles. He then infiltrates the quadriceps tendon, the subcutaneous tissue incision, femoral nerve field blocks (lateral and medial), the saphenous nerve field block, the arthroscopy portal incision sites, the tibial tunnel incision and the femoral exit pin incision.

"ACL surgeries are a very common outpatient surgery and the young people needing them are the ones that can be most prone to opioid addiction," he says. "This protocol allows us to do opioid-free ACL surgery."

Over-the-counter pain relievers

Tylenol or ibuprofen work well on a headache, but can they handle the post-operative pain of outpatient surgery? Yes, says Asif M. Ilyas, MD, FACS, medical director at the Orthopaedic Surgery Center at Bryn Mawr (Pa.) Hospital. Dr. Ilyas's study found that non-opioids like Tylenol and ibuprofen are as effective as opioids like oxycodone for outpatient hand surgery.

The study included 100 patients scheduled for primary unilateral carpal tunnel release (CTR) under local anesthesia, who were blindly given either 5 mg of oxycodone, 600 mg of ibuprofen or 500 mg of acetaminophen post-operatively.

"There was no clinically significant difference in pain experience or pill consumption whether patients received an opioid or non-opioid after surgery," says Dr. Ilyas, also the program director of the hand surgery fellowship at Rothman Institute and professor of orthopedic surgery at Sidney Kimmel Medical College at Thomas Jefferson University, both in Philadelphia, Pa.

Dr. Sigman coincides his use of Exparel with a multimodal approach to pain management that includes Tylenol, Celebrex and, at times, gabapentin. Although he discharges patients with 5 oxycontin immediate-release pills, Dr. Sigman discourages their use. "We tell patients that we can't take away all the pain, but as long as it's reasonable, try not to take the narcotics because they are so addictive."

Pre-op counseling

When Dr. Ilyas tried pre-operative opioid counseling, he started with a group of patients undergoing carpal tunnel release. He was familiar with studies where 76% of CTR patients filled at least 1 prescription for opioids following surgery and 14% filled a prescription beyond 90 days after surgery.

His results? Patients who were counseled about opioid use used fewer prescribed opioids than those without counseling. The counseled patients also looked to nonprescription painkillers to help with their pain more than those in the uncounseled group, Dr. Ilyas notes. The study involved 20 CTR outpatients in each group (the counseled, and the uncounseled). All patients were prescribed 10 pills of Tylenol #3 (325 mg of acetaminophen and 30 mg of codeine) after surgery.

"There was two-thirds less opioid use in those who were counseled," says Dr. Ilyas, who has patients watch a video on a tablet while they're in their pre-op stretcher. "We make them understand the pros and cons of opioids, what are the right ways and wrong ways to use them, and how long they should use them."

Aromatherapy

The nose knows what overcomes post-operative nausea, and it doesn't have to be an antiemetic medication. When inhaled, alcohol, peppermint oil, oil of ginger, spearmint, lavender, cardamom and tarragon can make patients feel better when used alone or when combined, studies show. In one study, a group of patients who felt nauseous post-op inhaled 70% isopropyl alcohol, ginger oil or a blend of the essential oils of ginger, spearmint, peppermint and cardamom off of a gauze pad. All of the patients had a shift toward reduced nausea, with the ginger and ginger blend groups having the biggest shifts, says Ron Hunt, MD, who conducted the study based on his interest in aromatherapy that he acquired while working for years as an anesthesiologist. Among the ways to deliver aromatherapy to patients include nasal clips and inhalers.

Integrated therapies

Blocks and medication can keep a patient's physical pain at bay, yet integrated therapies like guided imagery, acupuncture and massage keep a patient from the medicine cabinet because they work to make a patient feel emotionally better about their pain, says Ankit Maheshwari, MD, a University Hospitals Cleveland (Ohio) Medical Center anesthesiologist who finds benefits to applying the techniques before, during and after surgery.

"Even simple breathing and relaxation techniques can really make a dent at decreasing the intensity of pain and the perception of pain," says Dr. Maheshwari, clinical assistant professor of anesthesiology at Case Western Reserve University School of Medicine, also in Cleveland.

To get the best use of integrated therapies, give patients educational material on meditation and breathing techniques 7 to 10 days before their procedure so they can familiarize themselves with them, says Dr. Maheshwari. He even uses guided imagery intraoperatively to distract anxious or pediatric patients through procedures such as a block.

"I'll start by asking the patient to take a mental walk through their house. I take them room by room, asking them to count the number of doors and windows and to imagine looking at the furniture. Next thing you know, the procedure is done," he says. "The patient is usually meaningfully calmer and even surprised that the procedure went so quickly."

The use of integrated therapy continues to provide benefits in the University Hospitals Cleveland Medical Center recovery room, where patients can use their phone to gain access to guided imagery messages available on the hospital's website. Outpatients can return to the facility for acupuncture and massage, which can help with post-op issues such as constipation and insomnia, says Francoise Adan, MD, activity director and medical director of the hospital's Connor Integrative Health Network.

"Patients want to know they have tools in their toolbox, such as breathing techniques and meditation," says Dr. Adan, "and that they do not have to be dependent on medication or their treatment team."

Handle with care

Use opioid-free strategies as much as possible, yet keep in mind that opioids still have an important role in caring for some patients. "But it's all about safe use," says Dr. Ilyas. "We need to sharpen physician prescribing for opioids, educate our patients on their safe use, and better understand what a patient needs after various types of surgery." As Dr. Sigman is quick to remind, "Using opioids for post-operative pain management has inadvertently contributed to the epidemic we face across our country." OSM