A common shoulder surgery has become a testing ground for some novel painkilling techniques as doctors seek to reduce the use of prescription narcotics known as opioids.
Rotator-cuff surgery, which aims to repair a shoulder tendon that can get torn from sports, a bad fall or simple wear and tear, is among the most painful for patients to recover from. If nonaddictive painkilling techniques can be shown effective with this surgery, doctors hope they will be more widely adopted especially by orthopedic surgeons, who are among the most frequent prescribers of opioids.
The techniques might include injecting a nonaddictive anesthetic at the base of the neck to block pain signals, or sending a patient home with a catheter implanted under the skin to deliver doses of anesthetics for several days. Wearable icing devices and mechanical stimulation of the surgical site can reduce pain and swelling during physical therapy. And drug regimens seek to steer patients within a few days toward common medications such as Tylenol.
Some of the techniques to control pain have been around in some form for years. But their use in combination, known as multimodal management, is gaining popularity amid mounting concern about an epidemic of opioid addiction. A July 2015 study in Mayo Clinic Proceedings found one in four people who were prescribed a narcotic painkiller for the first time progressed to long-term prescriptions, putting them at risk for dependence and dangerous side effects.
“As a profession we prescribe too many narcotics for too many patients,” says Andrew Rokito, chief of the division of shoulder and elbow surgery at NYU Langone Medical Center’s Department of Orthopaedic Surgery in New York. “Barring unusual circumstances, we should be able to get a good handle on patients’ pain after surgery and minimize their opioid use.”
Celestino Sepulveda, 61, a plastic surgeon in Poughkeepsie, N.Y., who goes by the nickname Ed, first had rotator-cuff-repair surgery seven years ago after injuries from playing tennis and golf. He says he was in terrible pain after the procedure and took the narcotic painkiller oxycodone, which made it hard to stay awake and gave him nightmares. Four years later he had a fall and re-tore his rotator cuff so badly he couldn’t raise his arm.
He chose Dr. Rokito for a new surgery in 2014. During the surgery an anesthesiologist implanted a catheter at the base of Dr. Sepulveda’s neck attached to a continuous-infusion pump to deliver anesthetic to the shoulder area for the next three days. Dr. Sepulveda says he felt no pain during the time it was in use. He says he never needed any narcotic medication and was able to manage subsequent pain with Tylenol. Now, he says, he can golf, cycle and play tennis as well as he did before his injuries.