To learn how other surgeons in the United States have implemented ERAS pain management practices, Surgical Products connected with Anita Gupta, D.O., Pharm.D., member ASA Committee on Pain Medicine; Dr. David B. Auyong, attending anesthesiologist, medical director at Lindeman Ambulatory Surgical Center, Virginia Mason Medical Center; Dr. Deborah Keller, a colon & rectal surgery doctor in Houston, Texas; and Dr. Lawrence Volz, director of ERAS programs for Dunes Surgical Hospital and Mercy Medical Center-Sioux City, Iowa.
What role do you think opioids play in pain management?
Gupta: Traditionally opioids have played a significant role in pain management regimens. Frequently they are used as the first option for treating chronic pain. This, in part, can be explained by Medicare reimbursement systems that have previously not favored multimodal treatment approaches. In the period between 1991 and 2013, the number of opioid prescriptions increased from 76 million to 207 million. This increase has paralleled the increase in opioid related morbidity and mortality with an estimated 44 people dying daily of opioid overdose. Approximately 80 percent of these overdoses are unintentional. This epidemic has certainly led to a reimagination of the role of opioids in pain management both acutely and chronically. Multimodal analgesic approaches have developed with an aim of reducing overall opioid use. Moreover, within the realm of acute postoperative pain regional analgesia techniques including epidurals, nerve blocks as well as local anesthetic infiltration either single shot or via a catheter around an incision are being used increasingly with good effect. In the chronic pain realm, steroid injections, radiofrequency ablation, nerve blocks have come to the fore as alternatives to opioids.
Keller: Opioids have traditionally been the go-to for post-operative pain relief, both for in-patient and outpatient procedures. Just in the few years that I’ve gone through training and starting practicing, I have seen the reliance on opioids in clinical practice decrease, with evidence of the benefits of ERAS protocols, TAP blocks, long-acting liposomal bupivacaine, and other agents available.
Volz: I think opiods were traditionally the go to medication for pain. They are still the most potent medications we have for severe pain and still play a role. Ideally though we want to minimize their use as much as possible and the ERAS techniques greatly help with that. We have learned over the last 10 years that managing pain from multiple aspects leads to decreased narcotic usage and ultimately improved outcomes.
I believe that implementing and fine tuning multimodal and regional techniques we will be able to eventually not need narcotics for pain control for routine surgery.
This is one in a five-part series. These experts also answered: