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Alternative post-op pain management can help with addiction

March 15, 2017

Surgical oncologists can help reduce the risk of patients developing opioid dependence, according to a speaker at the 34th Annual Miami Breast Cancer Conference, held March 9–12 in Miami Beach, Florida.

“Prescription drug overdose is an epidemic in the United States,” said Patrick I. Borgen, MD, chair of surgery and director of the Breast Cancer Program at Maimonides Medical Center in Brooklyn, New York.

More than 70 million patients are prescribed opioids for postsurgical pain management each year, Borgen said. “One in 15 patients given opioids for pain will get addicted; it’s a number I have trouble getting my mind around.”

“All too often, in far too many communities, the treatment is the problem,” Borgen said, quoting former Centers for Disease Control and Prevention Director Thomas R. Frieden, MD, MPH.

Long-term postoperative prescribing is key. Among elderly patients undergoing low-risk surgeries, 10% are still taking opioids a year later, for example.

“In patients undergoing soft tissue or orthopedic procedures, 6% of patients continued on new opioids 150 days after surgery,” he said. “One year after elective spine surgery, a third of all patients were still using opioids.”

Diversion from medical use to the illicit street trade is also common, he noted. “It’s a national emergency,” he said. “Both our elderly and our children are at risk. Compared to nonathletes, adolescent boys who participate in organized sports have twice the risk of being prescribed an opioid medication and four times the risk of misusing opioids to get high.”

One place to tackle the epidemic is postsurgical prescribing, Borgen said. Surveys show that nearly 60% of patients prefer nonopioid pain medications and that 30% express fear about addiction, he noted.

One alternative to sending breast surgery patients home with opioids or opioids prescriptions is the intraoperative administration of a novel nonopioid pain drug, bupivacaine liposomal injectable suspension. It is “the only single-dose local analgesic that provides long-lasting analgesia with reduced opioid requirements and without a need for catheters or pumps,” Borgen said.

Bupivacaine provides pain relief for more than 48 hours. “That’s the window for our breast cancer patients,” he noted.

Ten clinical studies of its use in wound infiltration during different surgical procedures (at doses ranging from 66 mg to 532 mg) show that the most common adverse reactions are nausea, constipation, and vomiting. Maximum dose should not exceed 266 mg (20 mL, 1.3% of undiluted bupivacaine), he advised.

It is slowly deep-tissue infiltrated into the soft tissues of the surgical site.

Because bupivacaine does not diffuse, “it matters how you administer it,” Borgen emphasized. “Injection technique is the key to victory here. When I hear it didn’t work, it’s almost always because the injection did not cover the pain field.”

Bupivacaine is injected layer by layer. For example, during a mastectomy procedure with immediate tissue expander-based reconstruction, bupivacaine liposomal injection suspension solution is infiltrated along the inframammary fold around the perimeter of the breast and then into the pectoralis muscle near where it meets the sternum, Borgen explained. A final submuscular infiltration is delivered into the pectoralis muscle itself.

Borgen presented the case of a 79-year-old, obese, hypertensive patient undergoing this procedure. After intraoperative bupivacaine, she was given acetaminophen and the nonsteroidal anti-inflammatory drug (NSAID) ketorolac. No postoperative intravascular analgesia was required.

Shifting away from opioid-based postoperative pain management helps individual patients and has societal benefits, as well, Borgen said.

“You’re talking about reducing readmissions and ER [emergency room] visits,” he said. “That’s something to be enthusiastic about.”

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