Doctors seek to reduce the use of opioids to control pain, such as shoulder surgery.
As part of a national drive to reduce the use of narcotic painkillers, shoulder surgeries such as rotator-cuff repairs are becoming a testing ground for some of the more novel approaches to pain management.
Operations to repair torn rotator cuffs, which attach the upper arm to the shoulder blade, have increased sharply over the last two decades, in part as the aging population seeks to maintain an active lifestyle. Nearly two million patients a year seek help for rotator-cuff injuries, and about a third of those require surgery, according to the American Academy of Orthopaedic Surgeons.
Rotator-cuff surgery, which aims to repair a shoulder tendon that can get torn from sports, a bad fall or simple wear and tear, is among the most painful for patients to recover from. If nonaddictive painkilling techniques can be shown effective with this surgery, doctors hope they will be more widely adopted especially by orthopedic surgeons, who are among the most frequent prescribers of opioids.
The techniques might include injecting a nonaddictive anesthetic at the base of the neck to block pain signals, or sending a patient home with a catheter implanted under the skin to deliver doses of anesthetics for several days. Wearable icing devices and mechanical stimulation of the surgical site can reduce pain and swelling during physical therapy. And drug regimens seek to steer patients within a few days toward common medications such as Tylenol.
Some of the techniques to control pain have been around in some form for years. But their use in combination, known as multimodal management, is gaining popularity amid mounting concern about an epidemic of opioid addiction. A July 2015 study in Mayo Clinic Proceedings found one in four people who were prescribed a narcotic painkiller for the first time progressed to long-term prescriptions, putting them at risk for dependence and dangerous side effects.
Some painkilling techniques surgeons are using to reduce the use of addictive opioid medications.
Single-dose regional nerve block: An anesthetic drug is injected at the base of the neck to block pain after surgery for up to 24 hours.
Prolonged continuous nerve block: Patients go home after surgery with a catheter implanted at the base of the neck to deliver anesthetic to the shoulder area for two to three days.
Minimal narcotics: After a single-dose nerve block, a short course of opioid medication is prescribed to ease the transition before switching to Tylenol.
Cryotherapy: Home devices that fit over the shoulder circulate cold water though a pad to help reduce swelling and pain.
Rehabilitation: Physical therapists might use muscle-stimulation devices and ultrasound to reduce pain and swelling and aid in healing.
Source: Dr. Andrew Rokito, NYU Langone Medical Center
In a study of 85 patients, published online in April in the journal Arthroscopy: The Journal of Arthroscopic & Related Surgery, researchers at the University of Chicago reported that a group sent home with a three-day continuous nerve block had better pain control, used fewer opioids and slept better than patients given a single injection at the time of surgery.
That often leads rotator-cuff patients to take large dosages of narcotics, such as oxycodone and hydromorphone, that can cause nausea, vomiting, and over-sedation, according to a review co-authored by Dr. Rokito and published online in April in the Journal of Shoulder and Elbow Surgery. Patients may have trouble breathing and end up in the ER or the hospital. Taking narcotics can also decrease a patient’s tolerance for pain, leading them to take more.
The level of pain from rotator cuff surgery can vary by patient, says Derek Cuff, a surgeon at Suncoast Orthopaedic Surgery & Sports Medicine in Venice, Fla. A study he led of 181 patients who had rotator-cuff surgery found that patients who used narcotics before surgery, smokers and younger patients were more likely to have higher pain levels in the first postoperative week. The study was published online in February in Arthroscopy.