While U.S. overdose deaths attributable to opioid use continue to rise year after year, healthcare providers are working to combat the crisis by developing new strategies to limit post-surgical narcotic use in pain management. At one Virginia hospital, an innovative approach blending two distinct procedures is showing promising results with certain urological surgery patients.
John V. Booth, MD is North American Partners in Anesthesia's chief of anesthesia, and OR medical director for HCA Healthcare, at Richmond, Va.-based Retreat Doctors Hospital.
Dr. Booth took the time to discuss a unique process that has been successful in reducing the need for opiates among some post-operative patients.
Editor's note: Responses have been edited lightly for length and style
Question: How is using Enhanced Recovery After Surgery with Transversus Abdominus Block helping to reduce long-term opioid use after surgery, and what makes this different from other approaches now in use?
Dr. John V. Booth: America is in the midst of a narcotic addiction epidemic. What we've learned is that no one section of the population is immune to this risk. Indeed, older adults often have their first narcotic exposure through surgery, so the surgical period presents us with a unique opportunity to reduce exposure to narcotics.
TAP is a technique that uses ultrasound to deposit local anesthesia in the abdominal wall. Performed prior to surgery, TAP can reduce pain input throughout the intraoperative period, and it may also reduce muscle spasm post-operatively.
ERAS protocols and regional anesthetic techniques are increasingly in use throughout the country. However, the rationale for their use has usually been to reduce pain in the immediate post-operative period. Instead, we are looking at the entire recovery, including home use of oral pain medications. We postulate that initiating TAP blocks prior to surgery may reduce opioid use, or even abolish the use of opioids well beyond the hospital stay. If we can eliminate narcotic usage, we reduce exposure to patients and therefore, hopefully, reduce the risk of addiction. We believe this is a fairly novel approach.
Q: Both ERAS protocols and TAP blocks have been in practice for nearly 20 years. What inspired the idea to combine them as a way to better manage post-surgical pain?
JB: ERAS is usually used as a catch-all phrase to package together different elements that can improve recovery after surgery; these elements may include oral pain medications, oral fluids, IV fluids, and pain blocks. As such, regional anesthesia has often been part of ERAS for open surgical techniques such as laparotomy. What has changed in recent years is an appreciation that laparoscopic surgery still can have appreciable pain and may also benefit from regional techniques, such as TAP blocks. My colleague at Virginia Urology, David Glazier, MD, initially approached me last year concerning this issue. As an expert on urogynecology, he was very aware of both the immediate pain concerns and the longer-term pain risk related to muscle spasm with pelvic reconstructive surgery. Through these conversations, and with the support of Beth Matish, CEO at HCA Retreat Doctors Hospital and OR Director Deb Owen, and my colleagues and the leadership at NAPA, we were able to put forward a proposal to address these issues.
Q: How are patients engaging with their own pain management and responding to this approach?
JB: We are starting to see increasing public engagement with these issues. Through education, and sadly, the personal experience of many patients, few lives remain entirely untouched by the opioid epidemic. Patients are adopting our process with enthusiasm and interest, and I do think this is vital to any program. Public education, beginning with the surgeon's office and preoperative assessment clinic, is critical to getting people engaged and educated. It takes a concerted effort from all stakeholders in the fight against addiction. If patients are not on board, I cannot envision any long-term success.
Q: How do you see the role of anesthesia developing in efforts to decrease narcotic dependency, reduce the national cost of opioid use, and improve the patient experience?
JB: I really do believe our role is pivotal in reducing the risk of dependency. Patients receiving an opioid prescription within seven days of surgery were 44 percent more likely to become long-term opioid users. Rather than just looking at anesthesia as impacting the hospital stay, we can and should look at how the perioperative period can influence the need for oral opioids at home after discharge. This area has not been extensively studied, but it is ripe for research and programs designed to look at the impact that perioperative management can have on reducing or even eliminating opioids. If we can do that, we can have an enormous impact on long-term dependency.