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Reduce the Use: One Patient’s Experience with Opioids

PumpThe biggest concern for some patients awaiting surgery is going under anesthesia and the intense and often uncontrollable pain they may experience after the procedure. But for one woman, the concern was about the potential side effects of the post-operative pain medications she would be prescribed.

In 2014, south Philadelphia resident Janet Daddi, 77, had surgery on her left shoulder as a result of arthritis. The procedure, a relatively routine one, was performed by David Glaser, MD, chief of the Shoulder and Elbow Service and an associate professor of Orthopaedic Surgery, and was completed successfully. However, following the procedure, Daddi was prescribed a regimen of oral opioids, which was the catalyst for what would become a slow and rocky recovery.

“After the surgery, I became so sick from the medication I was taking for the pain,” Daddi said. “The medication was too strong for me, and I felt very out of it. I knew that the surgery went well and that I needed to start physical therapy to get my shoulder back to normal, but I just couldn’t.”

Daddi said her reaction to the medications impacted her ability to recover quickly, ultimately extending her recovery time and leaving her feeling discouraged. Months later, Daddi was told she would need to undergo surgery on her right shoulder for the same arthritis problem. While she knew this could be a possibility, she couldn’t help feeling hesitant, given her first recovery.

But this time, Daddi’s care team was able to take her down a different path for a better recovery experience.

“She was the perfect candidate for an alternative pain management technique following her negative reaction to opioids with her left shoulder,” Glaser said. “There has been such a focus in the medical community on reducing the use of opioids following surgery for all patients, let alone someone who reacted like Ms. Daddi, that these alternative techniques are becoming more and more prevalent. What’s interesting is we’ve been using this kind of regional anesthetic technique in shoulder surgery for more than a decade, honing the multimodal approach and making advancements for better patient experiences.”

Glaser and a team of anesthesiologists recommended what is called a “continuous nerve block pain management technique” that would reduce the need for opioids post-operatively.

“This  approach, known as Multimodal Perioperative Pain Protocol (MP3), includes the use of multiple drugs that control pain through different ways, in addition to a continuous nerve block catheter attached to an ambulatory pain pump that delivers  local anesthetic around the nerves to numb a specific area,” said Nabil M. Elkassabany, MD, MSCE, an assistant professor of Anesthesiology and Critical Care, director of Orthopaedic Anesthesiology, and one of the anesthesiologists on Daddi’s second surgery. “Using the technique, numbing medications are delivered around the nerves supplying the shoulder via a portable pump for several days following surgery. The option is becoming more commonplace for patients who either do not handle oral opioids well, or prefer not to use them.”

Other analgesic [painkilling] techniques have been making their way into operating rooms recently as well, specifically during shoulder surgeries. The Wall Street Journal detailed some of these methods, one of which involves injecting local anesthetic – numbing medicine similar to Novocain used for dental surgery – at the base of the patient’s neck to block pain signals from the surgical area. The benefits of regional anesthesia – or nerve-blocks – go beyond just providing pain control after surgery; it can also provide an alternative for those who do not want to be under general anesthesia and/or are curious enough to watch their surgery as it happens.

“In these cases, where a minimally invasive procedure is being done, we can give patients a nerve-block  so that the procedure site is numb and the patient can tolerate the procedure with varying degrees of sedation,” Elkassabany said.

In addition to the nerve-blocks, other elements of the pain management protocol after shoulder surgery include prescribing drugs that control nerve pain such as acetaminophen (Tylenol), small doses of non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen – and small doses of opioids, as needed.

Daddi underwent her second shoulder surgery 18 months after her first, and had a completely different recovery experience. When she left the hospital just two days after the surgery, she went home with a nerve-block catheter so that she could continue her medication regimen with little to no oral opioids. In a recent CBS3 interview, she described the difference as “night and day.”

“It was absolutely amazing,” Daddi said. “I had the surgery on a Thursday, went home on Saturday, and my son removed the catheter on Sunday. I could have gone home on Friday, but I had asked to stay another day since I was still nervous about my recovery. In the days and weeks following surgery, it was like night and day. I was up and doing rehab much sooner and I no longer felt scared or discouraged.”

While Daddi was amazed at the difference, for her care providers who are using these techniques more often, the change was just what they’d expected.

“In Ms. Daddi’s case, as is the case with other patients, we carefully look at her medical history and design a pain management plan that will be a good fit for her and will optimize her recovery after surgery. It is very important to involve patients in the decision making process,” Elkassabany said.

Glaser repaired Daddi’s right shoulder, much like he did on the left side, noting that, “it was the same surgery as before, the same problem and repair, but the only difference was the anesthetic and post-operative pain management.” 

“Before the surgery and when I was in the hospital before going home, Dr. Glaser and Dr. Elkassabany both made sure I knew what to expect with the catheter and that I was comfortable with the recovery plan,” Daddi said.

More than four months since her second surgery, Daddi is still recovering well, and has become an advocate for these alternative options. “This procedure and recovery were far better than I could have ever expected,” she said, adding “it certainly put my mind at ease to know that these alternatives are available, and to be able to tell firsthand the difference avoiding opioids can make.”

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