Opioid Sparing Pathway: non-narcotic approach to pain management

Published 03/06/2018
Drs. Michael Bradley and Henry Cabrera ease pain without opioid side-effects


There are very few societal issues that have caught widespread attention more than the opioid crisis. For years, opioid-based drugs have been administered to patients during and after surgery for their effectiveness in eliminating pain. But the negative effects of these drugs, pharmaceutical derivatives of heroin, can range from nausea to dependency. In an effort to combat the opioid crisis, two members of the South County Health medical staff, anesthesiologist, Henry Cabrera, MD, and orthopedic surgeon, Michael Bradley, MD, have acknowledged the problem and are doing something about it, without sacrificing patients’ outcomes or experience.

“The pendulum has swung,” Dr. Bradley said. “We’re not loading people up with narcotics to eliminate pain. We’re having them understand that you will have some pain and we’ll help you get through it.”

Drs. Cabrera and Bradley recently collaborated on an opioid sparing pathway to minimize, or in some cases eliminate, opioid use for orthopedic surgical patients.

“Our goal is to get patients out of the hospital sooner and healthier, without the negative side effects of these drugs,” Dr. Cabrera said. “For years we were trained to use narcotics to get patients’ pain scores down to zero. Anything above a four was unacceptable. To follow the opioid sparing pathway as it is intended, medical staff and patients need to recognize and accept that there will be some pain. It’s a complete cultural change.”

The physicians describe opioid sparing as a four-part pathway, “a multi-modal attack on pain.” Green Line Apothecary, a local, independent pharmacy in Wakefield is participating in the initiative.

Three days prior to surgery, patients can go to Green Line Apothecary to obtain a blister pack of pre-ordered medication. Each pack contains an analgesic such as Tylenol, an anti-inflammatory medication, gabapentin (a neuropathic pain pill), and a narcotic. The pack also contains a blood clotting medication, unrelated to pain.

“We never used to start treating before the surgery happens. Part of the theory behind this is that we reduce any inflammatory processes that occur by treating it before it actually happens,” Dr. Cabrera said.

The intra-operative section, which effects patients during surgery, has been addressed with the use of a spinal anesthetic as opposed to a general anesthetic.

“We do nerve blocks whenever possible. That decreases the amount of narcotics patients would need afterwards,” Dr. Cabrera said.

The post-operative part of the pathway addresses the types of drugs given between the time a patient is discharged from the recovery room and then discharged from the hospital. When appropriate for the patient, pain is controlled mainly with non-narcotic options. This helps to reduce nausea, constipation, and other adverse side effects of pain-killing narcotics that delay recovery.

The physicians recently added a fourth part, post-discharge, to address a patient’s comfort from the last day in the hospital to about a week afterwards.


A new mindset
From the patients’ perspectives, anesthesia and pain are the most concerning aspects of surgery. From a patient care perspective, the pain scale is considered to be the fifth vital sign, after body temperature, pulse rate, respiration rate, and blood pressure. Whenever a patient indicates that he or she is in pain, common practice is to administer a narcotic for relief.

At South County Health, this process change has already begun with re-education and a new mindset for physicians, nurses, and patients, Dr. Cabrera said. Representatives from nursing, pharmacy, performance improvement, physical therapy, and home health - key services for the orthopedics center - meet regularly to ensure that the pathway is effectively used.

The cultural change also extends to physical therapy. In the past, patients would take a pain relieving narcotic prior to their therapy. Using the pathway, non-narcotic analgesics are taken pre- and post-therapy so that the patient can better tolerate the discomfort of physical strain. The goal, however, is always to balance patient comfort with positive outcomes.

“If the level of pain begins to compromise patient success, we’ll reassess the pathway used for that patient and change as necessary,” Dr. Bradley said.

The pathway was rolled out in December 2017. The South County Health Orthopedics Center was used to introduce the initiative, given the volume of patients who receive hip and knee surgeries at South County Hospital. To date, approximately 200 patients have benefitted from the method. Some of the orthopedic patients who have undergone recent surgery using the opioid sparing pathway, were given narcotics for pain during previous surgeries.

“Anecdotally, a couple of people have called with concerns about how much pain they are in, but it looks like our pain scores are not going up, and people are getting out of the hospital quicker,” Dr. Bradley said.

Building on the pathway’s success
While the pathway was originally intended for use in orthopedic patients, Dr. Cabrera adapted the pathway to be used in other surgical specialties. It is believed that no other hospitals in New England have addressed the opioid crisis and narcotic use to this scale.

“There was no model for administering non-opioid options for pain relief with surgical patients. We had to create our own,” Dr. Cabrera said.

“This is really changing the way we look at perioperative pain. I haven’t seen it to this scale. It’s no longer ‘what’s your pain, here’s your pill’ mindset, but ‘how can we help you’. Ice, relaxation techniques, Reiki – whatever works, we try it,” Dr. Bradley said.

The opioid sparing pathway is designed to be the default in post-operative pain management, understanding that narcotics will continue to play a role in patient care when necessary.

In March or April, the first quarter results of admitted patients will be available. Discharged patients who are rehabilitating at home are surveyed at intervals of six weeks, three months, and six months. Those results will also be factored into the measure of success.

“It’s successful already because it’s changing the way people think, and it’s addressing and acknowledging the opioid crisis,” Dr. Bradley said.