Thursday, January 23, 2020
Changing the Paradigm of Postoperative Pain Management
Dr. Scott A. Sigman MD is a fellowship-trained orthopedic surgeon practicing in North Chelmsford, MA. He is also a fierce advocate of opioid-sparing surgery, speaking around the world to shift the culture of pain management. He will be sharing his insights with us at the 2020 Orthopedic Value-Based Care conference. In this interview, he talks about the urgency of changing pain management culture, the struggle to do so, and why orthopedic surgeons must take the lead.
As told to Lauren McGill. Edited for clarity and conciseness.
Why are you passionate about changing the culture of pain management?
I think we were sort of misled as physicians. We were told that surgery is painful, which is true, and that you have to make sure to treat patients’ pain, which is also true. But then we were told to use opioids because they’re inexpensive and really not very addictive. And that couldn’t be anything further than the truth, as we are now aware.
My passion really comes from trying to change the paradigm so we can safely and effectively operate on our patients without getting them addicted to opioids.
How much progress has been made in awareness/acceptance of the need for opioid-sparing surgery?
The culture of pain management with the use of opioids in the United States really built up over decades and it is still a struggle to communicate to treating physicians that there are perioperative opioid alternatives. There have been incredible changes in techniques available so now, for the most part, surgeries can be opioid-free.
The younger doctors in training have all come on board quite quickly. It’s more the doctors who have been around for a while who are hesitant to make changes. We’re still hearing stories about prescriptions for 45 and 60 pills and there is no place for that type of prescriptive habit.
The good news is that when I first started lecturing about this seven years ago we could barely fill the room but, at this point, there is usually a minimum of 100 healthcare providers in the room to listen. We are really changing the paradigm of postoperative pain management.
What does the solution look like?
It has to go beyond prescription guidelines. The bigger solution needs to be about changing the entire culture. It’s not just to say, ‘I’m going to provide 60 pills or I’m just going to give you 30 pills, or I’m going to cut it down to ten pills. What really has to happen is communication with the entire perioperative team. It means educating all of the doctors and nurses that are involved in the care of a patient. That is where Dr. Zeev Kain’s ideas about the perioperative surgical home fit in beautifully.
We want to provide pain solutions while minimizing exposure to opioids. For example, using things like IV Tylenol or liposomal bupivacaine can be very effective. We’re also using iovera now which is a wonderful new medical device where we actually freeze the nerves around the knee a week prior to surgery and patients get upwards of three months of significant pain relief which dramatically reduces their pain in the perioperative period.
The culture of pain management with the use of opioids in the United States really built up over decades and it is still a struggle to communicate to treating physicians that there are perioperative opioid alternatives.
What about the cost of opioid alternatives?
As a general rule, if you take a look at the opioid alternatives that are out there, they are more expensive than the standard treatment protocols that are available. But if you look at the overall societal cost and loss of life with this epidemic, we’re obligated to spend money initially to save money later on.
I think the good news is that with a lot of lobbying to Washington and Congress and CMS, we are finally able to use non-opioid alternatives outside of the surgical bundle. As of January 1, 2020, we can get paid now as a surgery centre for the use of opioid alternatives, such as liposomal bupivacaine, with a J code. It is no longer coming out of the bundle so there is no longer a financial disincentive.
I think orthopedic surgeons were some of the leading prescriptive writers of narcotics in our country because of the painful procedures that we do, so we have an obligation now to correct that and change the way we’re doing things.
How does opioid-sparing surgery fit into value-based care?
You have to think about this at 36 000 feet – what we are trying to do is minimize the next wave of patients that have opioid addiction that require billions upon billions of dollars of our healthcare dollars to treat. And then there’s the cost to our local communities for emergency technicians and police to be able to deal with the overdoses.
The argument is made quite frequently that patients that have overdoses are not on prescription medications but on other drugs. But the question is not where the addiction ends up, but where the addiction started.
Value-based medicine isn’t just about the outcome within the time that a patient is in the surgery center. It’s includes the entire episode of care. So if you wind up having a patient getting addicted to opioids who then needs substance abuse treatment, you’re adding an enormous amount of expense and losing all the value created. Therefore, the overall cost of providing opioid-alternative care is more affordable and fits directly into the value-based plan.
Why is it important that orthopedic surgeons lead the way in opioid-sparing surgery?
Because what we do hurts! We are drilling holes into people’s bones and we’re using saws and it really creates a painful environment for our patients. I think orthopedic surgeons were some of the leading prescriptive writers of narcotics in our country because of the painful procedures that we do, so we have an obligation now to correct that and change the way we’re doing things.
Why are you looking forward to the OVBC 2020 conference?
I’ll be faculty at this conference but I’m also an attendee. We are currently converting our hospital-owned surgery center to a physician-owned surgery center. I'm looking forward to having conversations and learning from the diverse panel available. There is no better place than this conference to be in a room with such diverse people who truly understand the value-based equation.
In addition to his practice duties, Dr. Scott A. Sigman has served as the Team Physician for the US Ski Jump Team, the Team Physician at UMASS Lowell, and the Chief of Orthopaedics at Lowell General Hospital. In 2019, Dr. Sigman was elected as a Fellow of the Royal College of Physicians of Ireland, Faculty of Sports & Sports Medicine. Find him on social media (#followthefro) or come hear him at OVBC 2020 where he will be contributing to three exciting discussions.
In this session, an orthopedic surgeon and an anesthesiologist will provide their perspectives of how to put together a new generation of perioperative management programs.
Many organizations have learned the hard way about implementing VBC Is not easy and can result in revenue losses. This experienced panel will share their perspective and must-have elements in the operational, clinical, and financial aspects.
This is a highly practical session in which the speaker will discuss highly innovative approaches to manage patients undergoing orthopedic surgery. We all know that we should reduce the amount of opioids we use, but how should we replace these opioids? Come to the session and learn from a world leader in this area.