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 non-addictive painkilling techniques can be shown effective with this surgery‚ doctors hope they will be more widely adopted especially by orthopaedic surgeons‚ who are among the most frequent opioid prescribers.
The techniques might include injecting a non-addictive anaesthetic 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 anaesthetics 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 towards 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 study in July last year 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 of dependence and dangerous side effects.
“As a profession we prescribe too many narcotics,” said New York University Langone Medical Centre chief of the division of shoulder and elbow surgery Dr Andrew Rokito.
“Barring unusual circumstances‚ we should be able to get a good handle on patients’ pain after surgery and minimise their opioid use.”
Dr Celestino Sepulveda‚ 61‚ a plastic surgeon in New York state‚ first had rotator-cuff repair surgery seven years ago after injuries from playing tennis and golf. He said 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 Rokito for another operation in 2014. During the surgery an anaesthesiologist implanted a catheter at the base of Sepulveda’s neck attached to a continuous-infusion pump to deliver anaesthetic to the shoulder area for the next three days.
Sepulveda said he felt no pain at the time it was in use. He never needed any narcotic medication and was able to manage subsequent pain with Tylenol. Now he can cycle and play golf and tennis as well as he did before his injuries.
Catheters can be a problem for some patients‚ Rokito said. The devices don’t always stay in place and having a catheter protruding from the neck for several days can be “intimidating” for some people. Patients must get used to having their arms numb and weak for several days.
More often‚ Rokito said he uses single-dose injections of nerve blocks that can last up to 24 hours. He advises patients to start on a short course of opioid medication before the block wears off to ease the transition. After three or four days‚ Tylenol is generally sufficient.
Risks from injections include nerve damage and complications from leakage of the anaesthetic. Local anaesthetic also can be toxic to cartilage. But Rokito said the blocks are safe because they are directed at the nerves that supply the shoulder region and aren’t placed directly in the surgical site.
Operations to repair torn rotator cuffs‚ which attach the upper arm to the shoulder blade‚ have increased sharply over the last two decades‚ in part as the aging population seeks to maintain an active lifestyle.
Surgeons say the rough nature of suturing tissues back together and reattaching them to bone results in higher levels of pain than in many other types of orthopaedic surgery.
That often leads rotator-cuff patients to take large dosages of narcotics‚ such as oxycodone and hydromorphone, said a review co-authored by Rokitor and published online in April in Journal of Shoulder and Elbow Surgery.
New painkilling methods could counter addictions
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 non-addictive painkilling techniques can be shown effective with this surgery‚ doctors hope they will be more widely adopted especially by orthopaedic surgeons‚ who are among the most frequent opioid prescribers.
The techniques might include injecting a non-addictive anaesthetic 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 anaesthetics 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 towards 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 study in July last year 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 of dependence and dangerous side effects.
“As a profession we prescribe too many narcotics,” said New York University Langone Medical Centre chief of the division of shoulder and elbow surgery Dr Andrew Rokito.
“Barring unusual circumstances‚ we should be able to get a good handle on patients’ pain after surgery and minimise their opioid use.”
Dr Celestino Sepulveda‚ 61‚ a plastic surgeon in New York state‚ first had rotator-cuff repair surgery seven years ago after injuries from playing tennis and golf. He said 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 Rokito for another operation in 2014. During the surgery an anaesthesiologist implanted a catheter at the base of Sepulveda’s neck attached to a continuous-infusion pump to deliver anaesthetic to the shoulder area for the next three days.
Sepulveda said he felt no pain at the time it was in use. He never needed any narcotic medication and was able to manage subsequent pain with Tylenol. Now he can cycle and play golf and tennis as well as he did before his injuries.
Catheters can be a problem for some patients‚ Rokito said. The devices don’t always stay in place and having a catheter protruding from the neck for several days can be “intimidating” for some people. Patients must get used to having their arms numb and weak for several days.
More often‚ Rokito said he uses single-dose injections of nerve blocks that can last up to 24 hours. He advises patients to start on a short course of opioid medication before the block wears off to ease the transition. After three or four days‚ Tylenol is generally sufficient.
Risks from injections include nerve damage and complications from leakage of the anaesthetic. Local anaesthetic also can be toxic to cartilage. But Rokito said the blocks are safe because they are directed at the nerves that supply the shoulder region and aren’t placed directly in the surgical site.
Operations to repair torn rotator cuffs‚ which attach the upper arm to the shoulder blade‚ have increased sharply over the last two decades‚ in part as the aging population seeks to maintain an active lifestyle.
Surgeons say the rough nature of suturing tissues back together and reattaching them to bone results in higher levels of pain than in many other types of orthopaedic surgery.
That often leads rotator-cuff patients to take large dosages of narcotics‚ such as oxycodone and hydromorphone, said a review co-authored by Rokitor and published online in April in Journal of Shoulder and Elbow Surgery.
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