Vani Sabesan, MD, an Orthopedic Surgeon in the Levitz Department of Orthopedic Surgery at Cleveland Clinic Florida talks about the opioid epidemic and other alternatives.
Interview conducted by Ivanhoe Broadcast News in October 2018.
Tell me the opioid epidemic obviously it doesn’t seem to be getting any better. Is it a big problem with the older population and are we even addressing that?
Dr. Sabesan: Yes. The opioid epidemic has been escalating over the last twenty years. So it’s easy to talk about now, but it’s a crisis now that has sort of led up over the last couple decades. What we aren’t or what we are aware of is some of the statistics. We know that there are a hundred and fifteen deaths per day, we know that it impacts all walks of life, all ages, all you know backgrounds. What we probably aren’t as aware of is the elderly population. What I think that we were just discussing about is that patients that are older tend to have a lot of chronic problems. Whether it’s multiple joint problems or other pain generating problems what you find is many times there are multiple providers that tend to write pain medications for these elderly patients. But really we don’t really think of them as a at risk population. So, we’re not identifying them as at risk populationsand so I don’t think that our awareness as physicians is really that they are at risk or probably the most at risk due to there chronic disease to get opioid addiction.
And on that same line of thinking do you think that physicians when it comes to the older population is it like a fine line in the sense of well, they’re in pain they need something for pain. And we know opioids can be very—can help in that manner. So do you think physicians even feel sort of torn in a sense when it comes to treating their patients?
Dr. Sabesan: Well ever since we created pain as the fifth vital sign it’s been a critical conversation for every physician every healthcare provider with their patients. So none of us want to leave patients in pain but you know what I think that there’s a missed opportunity here because I think opioids are not the only way and they’re probably honestly not the best mechanism to treat patient’s pain. When you look at back pain, which is a very common problem that we see in our population. The studies have shown, and these are multi center high level studies, what the best management for that pain is, not surgery, not chronic opioids but exercise. The activity levels of patients perhaps ,our elderly population we need to get them to get out and walking or more active with therapy or execise. And that’s one critical way that we have a missed opportunity specifically for musculoskeletal pain. It can be a wonderful effective mechanism that doesn’t require opioids and doesn’t end up in addiction or dependence.
So what you are saying there can be simpler solutions to this growing problem. What about doctor and I know you’re a surgeon, shoulders and tell us about the surgery.
Dr. Sabesan: Yes, I do a lot of shoulder/elbow surgeries. And sometimes we do upper extremity traumas as well. In those surgeries specifically, look I’m going to apply what you asked to my practice. surgery is a critical event and we think of it as a painful event. We just surveyed a hundred patients in our musculoskeletal clinic in orthopedics. And you know patients really fear surgery because of the pain. So they think it’s painful, and they think that they need opioids to manage that pain. But what we took upon ourselves at the Cleveland Clinic is to say, okay we’re going to be leaders in this. And maybe we can change this algorithm, maybe we can change the conversations that we have with patients. What I did in my practice is we created a partnership. We said okay, patients we’re going to learn about your risk factors so we’re going to put risk assessment tools in place and then we’re going to change our opioid education. We’re going to change the patient education. And we’re going to say, hey by the way here’s a crisis that’s occurring, here’s how in Florida the legislature, the laws have changed. But let’s talk about ways that we can provide you alternatives. Maybe we can still make your recovery, your pain management successful and guess what, maybe even give you a better outcome . And so we started having these conversations over the last about six months to a year and I’ve had forty patients, can you imagine that get big shoulder—a shoulder replacement, a rotator cuff surgery and they’ve not taken a narcotic medication after surgery. So guess what we’ve been studying those patients because we don’t want to minimize outcomes. So we found that those patients have the same pain levels and guess what better outcomes after surgery. That means function and patient satisfaction. So maybe there’s a partnership here that we can do to actually provide patients better care.
Give me just a couple specifics doctor when it comes to that. Say the patient that we meet today who did have shoulder surgery he is in his eighties. How did you help him manage say postsurgical pain?
Dr. Sabesan: Yeah. So I’m doing another patient today, and that patient what we did is have a conversation before he even went to surgery, before he scheduled surgery and said, we’re doing some innovative research here and first of all I’m going to give you some education. Here’s the opioid crisis, here’s how it affects all Americans, but here’s how it could affect you. What we’ve found is with our chronic arthritis patients like the patient you guys are going to interview, thirty five percent of them are already dependent before they see me, so one is awareness. You don’t think of yourself being dependent you know when you’re having chronic pain. But the pain meds you took before surgery that makes it much more difficult after surgery to manage your pain so one is awareness. Two, we said we’re going to provide you some amazing multi-model pathways. A different algohithm of how we do surgery. What that means is we give you nerve agents, we give you a high dose anti-inflammatory during surgery. And then we do a block where we put local anesthetic around your nerves and that is effective in sort of providing pain relief for the first twelve to twenty four hours. Then we’re going to do something even more innovative and we’re going to study it with research where we infuse a local agent that is bond to a fat nodule. And over that fat nodule it lets it diffuse over the first three, four days so that we provide around the surgical site pain relief for the first three or four days. For that patient that was so effective he didn’t feel that he needed a narcotic medication. He was able to take over the counter pain relief medications and a high dose anti-inflammatory and that was all he needed. And he felt like he had the recovery to be able to do that.
So do you think—is the goal with what you guys are doing here at Cleveland Clinic, Florida, is the goal to make this more of a standard way, a universal way of care?
Dr. Sabesan: We’re trying to elevate our system, first of all we have to study it, make sure it works before we disseminate it or make it a universal standard of care. We’ve got to make sure we’re doing right by our patients. So first of all we studied it and we found such good success. It’s not going to be for every patient our patients that have high risk, high dependence we’re going to work with them with different modalities. But the idea is that educational tool and the partnership that’s an algorithm that’s reproducible for any field of surgery. Here at the Cleveland Clinic, we’re going to do that. We’re going to create a patient engagement, a partnership with our patients to address this problem right and make real solutions.
So this is something that patients and doctors need to be talking about with one another, prior to surgery, prior to any kind of treatment.
Dr. Sabesan: This is something whether a doctor and patient want to, because of the rules and the law in Florida this is something that is already in place. So you can choose to talk to your patients about it, you can choose to have that partnership or you can just provide them the law. To me, that tool of communication and education really has made the difference for our patients not feeling like they’re minimized and making sure we’re maximizing their outcomes.
Because the law is now—
Dr. Sabesan: Three days after surgery unless you have an acute pain exception seven days and that’s all you’re allowed to write for.
It’s in Florida only, I just found out.
Dr. Sabesan: It’s a state by state rule, there are other states that have that, but not to the extend to Florida, we’re kind of a leader on that.
I guess the last thing is just to not be afraid to discuss it and also you still will get pain management.
Dr. Sabesan: You bet. One thing we were talking about is you know patient’s fear or worry that they will be accused of addiction or abuse if they ask for pain management. I think the most important thing is one, that your patients need to feel open to be able to communicate with you. But what’s amazing is sometimes just by having that conversation and providing them different alternatives, honestly just sort of addressing the fact that surgery might hurt but it’s a contained or small amount of time and they will get through it. That encouragement alone is really can be a wonderful tool for patients. So one is to provide them alternatives and two, is to encourage them that they will get better. And the benefit of surgery is that many of our patients feel significantly better. It just might take a week or two weeks.
You’ve got to get over that point and that is a point where people can become dependent on opioids.
Dr. Sabesan: Yes. So quickly that’s the thing that we’ve learned is you know, patients feel that they have to take opioids. When what we’ve talked about to our patients is you can take over the counter pain medications like acetaminophen or antiinflammatories. Don’t forget the simple stuff. Icing, elevation, anti-inflammatory, and once you do that what you find is you get less of a peaks and valley. You’re able to maintain that recovery so much better. And so when you need a pain medicine you can still take it, but you’re only needing it every once in a while not as a scheduled type of thing.
(talking)
Dr. Sabesan: He still works he’s a legal. It was worrisome because he seems so old, wait until you see him he’ll come in a little button up shirt, a sweater. I mean he’s like a sixty year old. My next patient right now she drove from Sarasota, she’s getting a rotator cuff repair. People think minimally invasive surgery is the least painful it actually can be the most painful. And so rotator cuff or arthroscopic surgery she came from Sarasota. She’s worried about when she goes back, but she feels confident that we’ve talked about it and that she’s going to get these multi-modal things. She feels confident for her recovery that she’s going to be able to do this with minimizing amount of narcotics.
So is that also the point when you talked to the gentleman that we’re going to talk to later the same kind. Like if you encourage that patient and we’re going to make sure you will be okay.
Dr. Sabesan: Yes. Here are the tools and people don’t always know what else they can do. Here are the other tools, and we write it out for them. You can ice it, you can use over the counter medications, and the thing that we missed that you didn’t get that in our other soundbyte that we talked about was I think a critical component of it is early rehab. The earlier you can get therapy integrated in the more you can minimize the swelling, the more you can create motion in that joint the better a patient’s recovery is. Sitting in pain is not a good way for people to feel like they’re active in their recovery. When they participate with the rehabilitation early on, we’re doing an early mobilization program that really has been a huge benefit for patients. And the patient you’re going to interview he specifically got moving right away and that was why at two weeks he had full motion, can you imagine. I have a picture I can provide, full motion at two weeks out from a shoulder replacement.
He was very motivated about his recovery.
Dr. Sabesan: Yeah, so he engaged in it. He said part of it was he was very worried about getting the surgery because of his age. His son is a physician at Hopkins, and his son called me and he said, “Are you sure you know?” And I said well here’s what we’re doing, and your father is older but it’s very much impacting his lifestyle. So he can’t feel like he can do the things that he loves to do like golf. But forget about golf just eating, putting a box up on a shelf, taking care of his wife, doing those simple things around the house he couldn’t do. When it becomes that difficult and pain it impacts your life that much we need to be providing other alternatives than narcotic medications. That doesn’t solve the problem. (exactly) When I had that conversation with his son I mean his father was (there) all for it. He said, you know what if this can make me better and keep me as active as I’ve been that’s what I want.
When the patient is all in and already very positive.
Dr. Sabesan: We call it resilience, there’s an orthopedic surgeon that’s really studied this so his passion is one of his partners lost their daughter died of addiction. He was an orthopedic surgeon, and one of his partners became sort of a missionary for it. He says that resilience a patient’s attitude perception ability to recover from crisis is a critical component. But you can say that but at the same time how do we build resilience in our patients. Not everyone is going to do that, but we still need to take it upon ourselves to try right to build that. One is just saying hey, here’s other things and you’re going to be fine. I give patients phone numbers of other patients that are willing to talk to them because sometimes they just don’t realize they can get through it.
And they need that encouragement.
Dr. Sabesan: But I gave you guys another patient that was another advocate and she’s, can you imagine, she’s from New York she’s (in a) wheelchair bound and had a brain aneurysm an stroke. Her ability to metabolize opioids and actually the complications from opioids are much more severe for her in the elderly population. You have to be much more critically aware. They don’t have the same functions to metabolize them as a normal younger person so it’s much more critical over overdose. Just their respiratory system, they’re overall motor function, their dementia can really affect all of that. You have to be really aware in the elderly population. It’s not addiction, but dependence, and then just the complications which can lead to death. I mean but you don’t hear about those as much because you hear they died of a heart failure but you don’t know if they took too many and stopped breathing because we don’t know. It just not even in the algarhythm that you would think about.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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