Pain management 101 — Envision Physician Services' Dr. Adam Blomberg on pain management, recovery protocols and opioids

Envision Physician Services' National Education Director of Anesthesiology Adam Blomberg, MD, FASA, spoke to Becker's ASC Review about enhanced recovery after surgery protocols, opioids and the future of pain control.

Question: How can surgery centers enact ERAS protocols? Is it simply a matter of anesthesiologists collaborating with a surgical team?

Adam Blomberg: As national education director for Envision Physician Services’ anesthesiology division, I work with hospital, office and ASC based anesthesiologists. In a hospital setting, anesthesiologists may see the patient postoperatively, have coordinated care with the hospitalist and have more touch points with the patient. In an ASC setting, there’s only one touch point, so there needs to be coordinated collaboration with primary care, hospitalists, the surgical team and postoperative care to enact patient-centered ERAS protocols. The key is taking a patient-centered approach.

One beneficial aspect of an ERAS protocol is involving the surgeon and primary care physician in prehabilitation to prepare the patient for surgery. That may include getting patients’ a carbohydrate beverage the night before and up to two hours before surgery the morning of the procedure. The anesthesiologist and surgeon should work together on carbohydrate loading to ensure that the patient is well-nourished and hydrated so he or she goes into surgery in an optimal state.

As far as ERAS protocols intraoperatively, the anesthesiologist should work with the surgeon to ensure that they’re using multimodal pain management, including regional anesthetics and non-narcotic opioid-sparing medications such as gabapentin and NSAIDS. Postoperatively the surgeon may prescribe non-narcotic pain medications, while in a hospital setting this may be handled by the anesthesiologist.

Q: Do you expect regional nerve blocks and preoperative pharmacogenetic testing will continue to gain prominence as the nation battles opioids?

AB: Absolutely. Regional anesthesia is an imperative aspect of opioid sparing techniques. In some patients, if you use regional anesthesia you won’t need narcotics at all during the acute pain period.

Preoperative pharmacogenetic testing is a newer process that’s gaining prominence and I truly believe it will play a larger role in the future. In the past, when you gave a patient a certain opioid, if that patient still felt pain you might prescribe more. As a result of using more narcotics, patients became more tolerant and, sometimes, addicted.

In reality, we’ve found that patients can be non-responders to certain narcotics due to their pharmacogenetic profile. Today, we’re starting to use pharmacogenetic testing preoperatively so we can tailor narcotics to use one that the patient will respond to. By doing so, you can limit the use of narcotics and use only the amount needed to get patients through the acute pain process.

Q: What can anesthesiologists working with ASCs do to mitigate opioid usage?

AB: The key is narcotic-sparing, multimodal pain management. Preoperatively, nerve blocks are highly effective, as well as oral non-narcotic pain medications. Intraoperatively, use minimal narcotics in combination with other non-narcotic medications. Postoperatively, if you have pharmacogenetic testing there should be coordination with the surgeon prescribing a responsive narcotic as well as a round-the-clock non-narcotic. Even though non-narcotics won’t get rid of the acute pain, they will minimize it so you can use less opioids.

Q: What's something you believe the industry isn't talking about when it comes to opioids that it should be?

AB: The opioid crisis has been getting a lot of attention over the last year but it is not new. In the medical field we’ve been seeing this problem for years. Now that people are more aware of the problem, we have to be careful that we don’t let something else pop up that we’re not thinking about.

When everyone was talking about pain we wanted patients pain free. Now the focus is not just on managing pain but in doing so in a way that reduces patients’ exposure to opioids, when possible. The medical field as a whole is becoming increasingly aware of the importance of the use of multimodal pain management during the perioperative period as one strategy to help us curb this issue.

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