Surgery without opioids

How anesthesiologists are localizing pain to avoid prescriptions

Duke University Hospital anesthesiologist Dr. Jeffrey Gadsden poses for a photograph in his office at the Durham hospital, Tuesday, September 19, 2017. Gadsden is on the forefront of pain management research as he looks into ways of cutting out opioids in operations as well as post surgical treatment with regional anesthesia techniques. (Eamon Queeney)

DURHAM — As the opioid drug crisis escalates in North Carolina and state and national leaders across the nation scramble to combat the growing epidemic, anesthesiologists at Duke University and other leading health institutes are digging down to the root of the problem.

From 1999 to 2016 more than 12,000 North Carolinians have died from opioid-related overdoses, with the vast majority involving pain medications such as oxycodone or hydrocodone. In 2015 alone, there were more than 1,110 opioid-related deaths in North Carolina — a 73 percent increase from 2005 according to the most recent data. Wake and Mecklenburg counties led death tolls, followed by Forsyth and then Guilford counties.

“The problem with any opioid, it is so hard to know what dose will affect you,” says Dr. Jeffrey Gadsden, the director of the Regional Anesthesiology and Acute Pain Medicine fellowship and an associate professor at Duke University. “In a hospital, we are trained really well and we can control that dose of morphine, be able to predict what will be good for you but also manage the side effects — which the most dangerous is respiratory depression. If your breathing rate goes to zero that is game over.”

Control over your breathing rate is one of the primary jobs of an anesthesiologist, the other major component is pain management. And faced with a growing epidemic, Gadsden and his colleagues at Duke are pioneering methods to localize and control postoperative pain.

A peripheral nerve block pauses the pain during and up to days after a surgery.

“Your brain doesn’t understand that your arm is hurting, because it is just not getting that message,” said Gadsden sitting on the couch in his office on a sunny September day in Durham.

The block — sometimes more than one — is administered through a syringe and a local anesthetic. Novocaine, preferred by dentists, was used in the beginning days of regional anesthesia, but physicians have graduated to better, long-acting drugs such as Ropivacaine, which can last up to 15 hours.

But for major surgeries such as a total knee replacement, pain often persists for days. With catheters and ultrasound guidance, Gadsden can continue to administer that local anesthetic directly to the targeted nerve.

“After that block wears off after four or five days, they are over the hump — the intensity of the pain stimulus has gone away and they can ease into a lesser pain prescription,” explained Gadsden.

Multimodal anesthesia is a prime choice for orthopedic surgeries, but Gadsden said Duke has recently begun using blocks and epidurals — often utilized for pain management during child birth — to numb the stomach during abdominal surgery.

Peripheral nerve blocks don’t work for all cases — you break your arm but don’t need surgery; you are in a car crash with multiple injuries spread across your body — but reducing the number of opioids prescribed after common surgeries is a game-changer in the opioid epidemic, especially for those susceptible to chronic pain.

“What we’ve found is that if your central nervous system keeps getting the messages from the nerves coming out to say ‘it’s hurting, it’s hurting’ — even for just a few weeks after you broke it — you have a significant chance of your brain rewiring itself and begin to spontaneously generate those signals,” Gadsden explain. “So even after your arm heals and there is no more cause for pain, you could have chronic pain.”

Gadsden also says that patient expectations and education is a crucial part of the process. Waking up after the use of a peripheral nerve block means you won’t feel that part of your body, but it also doesn’t mean that you will be at a zero on the pain scale.

“You don’t want your patient to be in pain,” said Gadsden, “but flipping that chart around, and getting other doctors to understand ‘You don’t need to send your patient home with 90 pills after their finger surgery’ is important.”

And with the rise of patient satisfaction scores in a post-Obamacare health care industry, the key to that is also patient empowerment.

“I think this public health crisis is making people understand the need for alternative therapies,” Gadsden continued. “We’re beginning to see patients coming through saying ‘I’m well-read; I want you to minimize by exposure to opioids.’ We are really on the leading edge of that level of patient education.”

With doctors like Gadsden and institutions like Duke University leading the charge, the limitations on opioid prescriptions could change the epidemic more than any public policy.