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Overcoming Opioids Post-Op Alternatives

University of Maryland Shock Trauma Center nurse Amanda Fritsch on Jan. 19 checks the catheter delivering a drug that kept Stuart Anders’ injured leg numb for three days. Called a nerve block, the non-addictive numbing treatment substantially cut the amount of opioid painkillers that Anders otherwise would have been prescribed for his shattered femur.

BALTIMORE — A car crash shattered Stuart Anders' thigh, leaving pieces of bone sticking through his skin. Yet Anders begged emergency room doctors not to give him powerful opioid painkillers — he'd been addicted once before and panicked at the thought of relapsing.

"I can't lose what I worked for," he said.

The nation's opioid crisis is forcing hospitals, including in Northwest Indiana, to begin rolling out non-addictive alternatives to treatments that long have been the mainstay for the severe pain of trauma and surgery, so they don't save patients' lives or limbs only to have them fall under the grip of addiction.

Anders, 53, from Essex, Maryland, was lucky to land in a Baltimore emergency room offering an option that dramatically cut his need for opioids: An ultrasound-guided nerve block bathed a key nerve in local anesthetic, keeping his upper leg numb for several days.

"It has really changed the dynamics of how we care for these patients," said trauma anesthesiologist Dr. Ron Samet, who treated Anders.

An estimated 2 million people in the U.S. are addicted to prescription opioids, and an average of 91 Americans die every day from an overdose of those painkillers or their illicit cousin, heroin.

This grim spiral often starts in the hospital. A Harvard study published in the New England Journal of Medicine in February raised the troubling prospect that for every 48 patients newly prescribed an opioid in the emergency room, one will use the pills for at least six months over the next year. And the longer they're used, the higher the risk for becoming dependent.

Doctors and hospitals around the country are searching for ways to relieve extreme pain while at the same time sharply limiting what long was considered their most effective tool. It's a critical part of the effort to overcome the worst addiction crisis in U.S. history.

No one-size-fits-all solution

In trauma centers and surgery suites, there are no one-size-fits-all replacements for prescription opioids — narcotic painkillers that range from intravenous morphine and Dilaudid, to pills including Percocet, Vicodin and OxyContin.

They so rapidly dull severe pain that they've become a default in hospital care, to the point where it's common for patients to have an opioid dripping through an IV before they wake from surgery, whether they'll really need it or not.

Now, amid surging deaths from drug overdoses, some hospitals and emergency rooms are rethinking their own dependence on the painkillers, taking steps to make them a last resort rather than a starting reflex.

The new approach: Mixing a variety of different medications, along with techniques like nerve blocks, spinal anesthesia and numbing lidocaine, to attack pain from multiple directions, rather than depending solely on opioids to dampen brain signals that scream "ouch." It's known by the wonky name, "multimodal analgesia."

Consider colorectal surgery, so painful that standard practice is to administer IV opioids in the operating room and switch to a patient-activated morphine pump right afterward. A University of Pittsburgh Medical Center program ended that opioid-first mentality. Instead, doctors choose from a wide mix of options including IV acetaminophen and prescription-strength anti-inflammatory painkillers known as NSAIDs, anti-seizure medications such as gabapentin that calm nerve pain, muscle-relaxing drugs, and others.

That program, called "enhanced recovery after surgery," is getting some patients home two to four days faster following major abdominal operations, using non-opioid painkillers that are gentler on the digestive tract.

Without the opioid side effects of nausea, vomiting and constipation, patients may find it easier to start eating solid food and walking around hours after surgery. Some do still need a low opioid dose, but few require a morphine pump. And for those who go home earlier, the approach can save hundreds, even thousands, of dollars.

Region hospitals trying new approach

At MedStar Georgetown University Hospital, anesthesiologist Dr. Joseph Myers is adding to his non-opioid cocktail a long-acting version of the numbing agent bupivacaine that's squirted into wounds before they're stitched closed. Called Exparel, it's controversial because it costs more than standard painkillers. But Myers said it lasts so many hours longer that he recently used it for a cancer patient who had both breasts removed, without resorting to opioids.

Hours after surgery, she was "eating crackers and drinking ginger ale, and she says she's fine," he recalled.

Franciscan Health has a similar program in place at its hospitals in Crown Point, Dyer, Hammond, Michigan City and Munster, using regional nerve blocks, IV acetaminophen and Exparel.

"We started it to improve outcomes for our surgical patients," said Dr. Alan Gillespie, medical director of special projects for Franciscan Health.

"Our surgical patients now have fewer complications, get out of the hospital faster, recover better. As a side effect, yes, it will definitely help with the opioid issue, because these surgical patients will require, if any, certainly not as many narcotics."

Community Healthcare System, with hospitals in East Chicago, Hobart and Munster, stresses its patients try physical therapy instead of opioids after or in place of surgery.

"For somebody in a post-op situation ... ice is very effective, with guided exercises, in relieving pain," said John Doherty, vice president of therapy services for Community Healthcare System. He noted that opioids don't actually cure pain. "They don't even treat the cause, don't even treat the inflammation," he said.

Avoiding addiction

In Baltimore, Anders remembers waking up in the University of Maryland's Shock Trauma Center and telling doctors and nurses, "I am a recovering addict." Years earlier, another car crash had led him to a pain clinic that prescribed Percocet "just like candy," Anders said.

Before getting addiction treatment, he said, "I came close to losing my job, losing my wife."

Samet, the anesthesiologist, estimates that Anders' nerve block cut by tenfold the amount of opioids he'd otherwise have received for his latest injury.

Patients need to ask about these kinds of alternatives, he said, but they're not available at all hospitals. Nerve blocks are becoming more common for elective bone surgery than in fast-paced trauma care, for example.

But even if patients go home with only a small supply of an opioid for lingering post-surgical pain, Samet said, too often they get a refill from another doctor who assumes that prescription must be OK if a hospital chose it.

Not Anders. Sent home with some low-dose oxycodone, he discarded the last 20 pills.

"I didn't want them," he said, "and I didn't want nobody else getting their hands on them."

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Health Reporter

Giles is the health reporter for The Times, covering the business of health care as well as consumer and public health. He previously wrote about health for the Lawrence (Kansas) Journal-World. He is a graduate of Northern Illinois University.