A Critical Conversation

Three providers discuss the epidemic, the current landscape and future potential for opioid-sparing surgery.

Not long ago, the notion of opioid-sparing surgery — the process of reducing potentially addictive narcotics through pre- and intraoperative multimodal anesthesia regimens and limiting the amount of painkillers patients receive postoperatively — was scoffed at by many.

But a deadly crisis fueled at least partly by healthcare providers’ overreliance on opioids and a lack of transparency about the risks is forcing a paradigm shift in how facilities look at surgery and opioids. Outpatient Surgery Magazine recently sat down with a panel of experts in the area of opioid-sparing surgery for a passionate discussion on where we’re at, how we got here and what comes next.

(Note: Panelists’ responses were lightly edited for clarity and space.)

Meet the panelists

Scott Sigman, MD, is a nationally and internationally recognized leader in opioid-sparing surgery who practices at the Lowell (Mass.) General Hospital - Surgery Center at Drum Hill. He is also the team physician for UMass Lowell, the chief medical officer for OrthoLazer Orthopedic Laser Centers and the host of the popular podcast The Ortho Show.

Paul Sethi, MD, is a board-certified orthopedic surgeon who specializes in sports medicine conditions of the elbow, knee and shoulder. He is a leading research physician who speaks at academic and instructional medical conferences in the U.S. and abroad.

Karina Gritsenko, MD, is fellowship program director of the regional anesthesia and acute pain medicine fellowship and associate professor of anesthesiology, family and social medicine, and physical medicine and rehabilitation, at Montefiore Medical Center in Bronx, N.Y.

OSM: How did you become a proponent of opioid-sparing surgery?

Scott Sigman (SS): My opioid-sparing journey started about a decade ago. We had five young athletes who had undergone surgery in our local community and eventually succumbed to opioid overdoses. It was just a real shock to our community how hard we were hit by the epidemic. It showed how the operating room had become this inadvertent gateway to opioid addiction. It was also around the time the first of the long-acting anesthetics became available. Once there was an effective tool available that offered an opioid alternative, I never looked back. I dedicated myself to minimizing opioids at all costs to try and avoid doing harm to our patients.

Paul Sethi (PS): I became increasingly disheartened and frustrated with reading the local newspapers about how our youth were dying, secondary to opioid misuse. I remember thinking, “Oh, this isn’t me, or this isn’t us [surgeons] causing this,” until I became aware of medication diversion, and medication misuse and overuse. It was an epiphany that as surgeons we are the entry point. We may be the first exposure to a dangerous medication when people are in their most vulnerable state. That forced us to collectively rethink the paradigm that we should get ahead of the pain with opioids or prescribe so many. At one point, there were billboards around New York about pain-free surgery. Now, we can finally get to that point of pain-free surgery.

Karina Gritsenko (KG): My background has given me a core appreciation for the full gamut of pain, and I respect the concept of a good patient experience with minimal opioids. This comes from working in both the acute and perioperative setting, with an emphasis on regional anesthesia — a technique I absolutely love. I also have an interventional pain outpatient practice as well as certification in hospice care. This combination has strengthened my overall belief and dedication to mitigating acute pain and preventing persistent and chronic pain.

OSM: What is the most important thing for surgical leaders to understand about the state of opioid-sparing surgery right now?

SS: We have an obligation to take our patients safely and effectively through their surgical intervention without having them become addicted to opioids — especially in an ASC setting where most outpatient surgery is being performed. I feel strongly that an opioid-sparing philosophy needs to be baked into the ASC equation.

The number one issue most ASCs deal with is the cost associated with care. For example, an outpatient shoulder procedure that includes a regional liposomal bupivacaine block is about a $300 cost to the overall system. To me, that information must be included in the thought process. With Medicare and the pass-throughs that are available for these pain control products, commercial payers are recognizing the need for an opioid-sparing approach and are willing to pay outside of the bundle for it. For surgical leaders, a philosophy on the process of an opioid-sparing surgery should always be included in the process of doing business.

PS: Anyone who is providing outpatient surgical care should be in line with the most modern-day thinking — and that thinking involves opioid minimization. Underscored in that thought process is the fact that opioid utilization is going to cause more somnolence, it’s going to make leaving the surgery center more difficult, it’s going to cause more dissociation, more complications, a higher risk of trips and falls and a higher risk of respiratory depression and intraoperative complications that lead to transferring the patient to a hospital setting. Opioid-sparing surgery aligns perfectly with outpatient facilities’ mission to provide the most effective, most thoughtful care that can be administered and still allow patients to go home same-day.

KG: I think the challenge is understanding the concept holistically. Surgical leaders need to have a view from the top down and understand the microcosms that exist in the perioperative space regarding opioid-sparing surgery. For this concept to work, surgeons must have respect and trust for anesthesiologists, who must in turn serve as the gatekeepers for excellent, efficient care in the perioperative space.

OSM: How do you communicate with patients about the concept of opioid-sparing surgery and manage their pain expectations post-operatively?

SS: Consistent messaging throughout the entire process is crucial. From the moment a patient is having a conversation about consent for surgery, that conversation about how pain is going to be managed needs to be expressed in the exact same way by all the caregivers the patient encounters along the way. They need to know exactly what they’re going to expect as they go through the entire surgical process and beyond. For example, we used to do nerve blocks for the shoulder that would wear off at 12 hours or eight hours, which is the worst possible time. Nursing staff would need to repeat over and over, “When the block starts to wear off, make sure you start taking your pain medication, so you can be ahead of the pain.” These days, the blocks that we’re doing can last up to three days, so that’s not an issue. But the constant, consistent communication remains a must.

It blows my mind that there are doctors in our communities who are still writing scripts for 50 opioid pills for a rotator cuff surgery.
Scott Sigman, MD

Postoperatively, patients listen to their doctors. If they’ve had surgery, and the doctors are prescribing them 50 pills for pain, it says to the patient, “You’re going to be in pain for a while, but don’t call me because I gave you enough so that you shouldn’t have to call for a refill.” The messaging to patients — whether it’s intentional or unintentional — dictates what patients will do. It blows my mind that there are doctors in our communities who are still writing scripts for 50 opioid pills for a rotator cuff surgery.

PS: There are several steps to the process. First, there’s the preoperative education and the setting of expectations. There are the medications that you deliver before surgery and the intraoperative medications. There are also the postoperative medications and education associated with the understanding of normal postoperative pain. Within that, we utilize multimodal pain control — a mix of different medications that are safe to the individual — and only use opioids as our last resort. I challenge my patients here. I’ll say, “Don’t use the opioids, see if you can get through without it.” Setting that level floor is the real personalization component.

KG: I think “expectations” is a loaded term. In many cases, expectations can be an enemy to success. That said, poor satisfaction can often be traced to a lack of planning and upfront discussion with patients. Pain physicians and anesthesiologists in particular need to always be looking to predict how patients may recover — and communicate that information effectively. A knee replacement will feel different than a bunionectomy, which will feel different than a hemorrhoidectomy, and so on. When you’re speaking to patients about opioid-sparing procedures, you need to make sure they are fully aware of the expectations of ERAS (Enhanced Recovery After Surgery), the flow of the day and what will happen after their procedure. If there’s regional anesthesia involved, that requires a separate in-depth discussion. You also need to explain to patients what they should expect in the days following their surgery. For instance, most acute pain decreases significantly over time. In other words, their need for painkillers — opioids or otherwise — will trend downward. One of the most important moments in the opioid epidemic was when various pain societies and associations came together in 2016 to discuss appropriate opioid-dosing guidelines. Because of that, we now know that anything beyond a seven-day script isn’t needed for many surgical procedures.

OSM: What do you envision or hope for future?

SS: We’ve gotten pretty good at acute pain management, but there’s still an efficacy gap when it comes to treating sub-acute and chronic pain. I think what we need to do is establish techniques, ideas and concepts that are going to allow our patients to be pain-free even longer. I think what’s going to happen when it comes to pain management is that we’re going to be able to tell our patients, “Not only are we going to help you in the first few days in the acute phase, but if you develop new or chronic pain, there are things we can do longer-term that can help to prevent your need for opioids and addiction.”

PS: I think if we’re talking about moving beyond acute pain, we really need to consider all the holistic and the pharmaceutical approaches as well as the various mechanisms out there where we can unconventionally think about how to mitigate pain.

KG: We’re closing the gap between how we approach acute, persistent and chronic pain. Innovations in ERAS protocols and regional anesthesia have advanced our capabilities in ways that are invaluable to our patients. Now we’re asking: What else can we do? In what ways can providers aid in and improve our patient recoveries? More studies and data in this area are needed, and they will pave the way for what we do next. OSM