DULUTH — Dr. Christopher Davies and Neil Anderson — an anesthesiologist and a nurse anesthetist, respectively — acknowledge that they may be outliers in their field.
But that’s changing, the specialists said.
“I think it’s a slow transition, but the rest of the world is slowly coming around,” said Davies, a Duluth native who came to Lakewalk Surgery Center last year after completing a fellowship in pain management at Duke University.
He was talking about the treatment of pain, both in the operating room and for those suffering with chronic pain, and significantly reducing the use of opioids for those purposes.
The ills brought about by what’s variously described as the opioid epidemic or opioid crisis are well known. Much of the cause has been attributed to the excessive use of prescription opioids in pain control. The U.S. Centers for Disease Control and Prevention reported in 2016 that more than half of opioid overdose deaths involved prescription drugs, although more recent numbers are showing a gradual shift from prescription drugs as the culprit.
Last year, the Minnesota Health Collaborative — consisting of some of the state’s largest health providers, including Essentia Health — was formed with goals that included a further reduction in the already declining number of opioid prescriptions in the state.
“They’ve done some good work,” Davies said of the medical profession in general. “(They are) limiting the amount of opioids that can actually be prescribed after surgery by a surgeon now to usually … a seven-day course and X number of pills, where there was no limit before.”
Limits are essential, Davies said, because people can become hooked on opioids within 28 days.
“So if you’re taking opioids for a month after surgery, there’s a good chance you’re going to be taking them six, 12 months after surgery,” he said.
But Davies and Anderson are among those taking the limits to the next level. Although both said there are occasions when they’ll make use of opioids, they don’t make much use of them.
“If I use it at all, it’s extremely low-dose,” Anderson said. “I’ll bet nine out of 10 patients that I take care of don’t get opioids at all.”
One of the tools Davies and Anderson use is a non-opioid drug called Exparel. Manufactured by San Diego-based Pacira BioSciences, the drug functions as a nerve block, meaning it numbs the nerves serving the place in the body where the pain occurs.
“We’re still keeping them asleep, but it just takes far less medicine to do it,” Anderson said. “The advantage to that is obviously less pain, but with less pain means I get to use less medicine that causes more side effects — specifically opioids.”
Patients who previously had surgery with opioids report a less painful, more rapid recovery when Exparel or other nerve blocks were used, Anderson said.
But Exparel has run into controversy recently. The Minneapolis Star Tribune reported earlier this month that the University of Minnesota Medical Center had scaled back its use of the drug. The newspaper reported that Dr. Jacob Hutchins, medical director of the university’s acute pain service, had received more than $800,000 from Pacira since 2013, mostly to travel and speak on the company’s behalf. Hutchins encouraged using Exparel in “off-label” ways — those not approved by the U.S. Food and Drug Administration.
In a follow-up email after the Duluth News Tribune’s interview, Anderson wrote that Pacira hadn’t provided financial compensation to the Lakewalk team. Katherine Spenzos, the publicist who arranged the interview on Pacira’s behalf, also said Anderson and Davies hadn’t been paid by the pharmaceutical company.
In a statement, Pacira CEO Dave Stack said the Star Tribune had been contacted about “a number of inaccurate statements and mischaracterizations” but didn’t elaborate on what Pacira claims the disputed material was.
“We are proud to offer a non-opioid option to manage postsurgical pain, and we applaud hospitals and clinicians utilizing our product or any combination of non-opioid medications to mitigate needless opioid exposure,” Stack continued.
In a separate phone interview, Roni Evans, an associate professor at the University of Minnesota’s Earl E. Bakken Center for Spirituality and Healing, was cautious in her assessment of Exparel.
“We’d expect that there would be some high-quality research evidence supporting this, and that the benefits would outweigh the risks,” Evans said. “We’d want to make sure it was independent to some of the people that would be having conflicts with the pharmaceutical companies.”
The medical literature indicates “some questions about that, in my understanding,” she said.
In his email, Anderson wrote: “I think Exparel contacted us because we use a fair amount of the drug. We feel it’s benefited our patients in this setting. We use it according to the label — upper extremity surgery, primarily.”
He later characterized Exparel as “a spoke in the wheel of pain, not a magic bullet.”
But in surgery, Exparel is proving to be a step up over local anesthetics that were available in the past, Davies said.
“Their limitations include how long they’re going to last,” he said about the older drugs. “The longest one we had before this medication — probably about 12 to 16 hours max. With Exparel we can see up to 48, 72 hours, even longer in some cases. … That bridges the patient through the worst of the surgical pain.”
Once through those first few days, patients often are able to manage their pain with Tylenol or Ibuprofen, Davies said.
The disadvantages of opioids as painkillers go beyond the danger of patients becoming dependent, Anderson and Davies said.
Side effects can include difficulty urinating, nausea and difficulty breathing, Anderson said.
All of the issues a patient could experience after an operation in which opioids were administered can be largely avoided with nerve blocks such as Experal, Anderson said.
Added Davies: “As an example, a patient gets constipated from an opioid, which leads to a bowel obstruction, which leads to an emergency bowel surgery. You’re eliminating that horror.”
Although Anderson and Davies touted the use of Exparel during the interview, both spoke more about the larger picture of pain management with minimal use of opioids.
The two professionals, along with orthopedic and plastic surgery groups are using vacant space at Lakewalk Surgery Center to develop a pain management center that will look at non-opioid ways to treat pain, Davies said.
“There’s evolving research about: Can we actually fix the problem and not just treat the pain?” he said.
One example: Davies uses an implantable device to automatically administer medications. It’s considered both safer and often more effective in pain treatment, he said.
But no medications are sufficient in themselves for pain treatment, Evans said, because they address only the physical aspects of pain. They don’t address psychological and social aspects.
“We’ve become very conditioned to (the idea) that a pill will fix it,” she said. “We now know enough about pain to know that that’s just not going to be enough.”
For the other aspects of pain, approaches such as activity, mindfulness and cognitive behavioral therapy have been shown to be effective, Evans said.
“Opioids are one big thing right now that we’re paying a lot of attention to, but there’s a lot of opportunity to over-use other things as well,” she said.