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Testing a new approach to post-surgery pain

Proactive protocol hopes to reduce need for opioids

Joshua Cox can easily raise his arms above his head.  It's a simple move that was excruciating for Cox just four months ago.

"The rotator cuff was torn.  It was torn right in half," Cox said.

The 40-year-old dad from Rochester Hills also had arthritis in his shoulder.

"I'm a union ironworker, so we do the steel structures, buildings, bridges, skyscrapers," Cox said.  "It's just wear and tear over the years between the manual labor that I do and lots of softball, baseball over the years."

After six years of suffering, Cox had had enough.

"I got to the point to where I just couldn't take it, the constant pain in my shoulder," Cox said.

One of the reasons he says he put off surgery for so long was concern about needing to take opioid painkillers.

"I've had family members in the past have issues with them, so it was scary.  I didn't want to have to take pain medication," explained Cox.

Dr. Rob Keller and Dr. Nicholas Frisch, orthopedic surgeons at Ascension Crittenton Hospital, say it's a common concern.

"Patients are coming in fairly educated on the opioid crisis and so a lot of them are coming in saying, 'How can I find ways to not take a ton of opioids?'  They're scared. They're scared of becoming addicted," Keller said.

Keller says there is a clear problem with the standard reactive approach to post-surgery pain.

"You get some narcotics after surgery and whenever you have enough pain, you start taking them.  So people are scared to take these opioids, they wait, sometimes they wait too long, their pain gets out of control and then they have to take too many," Keller said.

Keller and Frisch are trying to address that issue by testing a proactive medication protocol.  

"You take nonopioid medications, scheduled so your pain never gets strong enough to require those strong opioid narcotics," Keller explained.

The medications are chosen to target different pathways of pain.

"There's Tylenol, everyone knows that, there's an anti-inflammatory; there's Tramadol which is a small pain medicine and then there's Gabapentin, which is a nerve medication," Keller said.

The idea came from Frisch's training at Rush University Medical Center in Chicago.

"We spent a lot of time looking at these different protocols for pain control," Frisch said. "I think a lot of that came from this shift towards outpatient surgery, and as people have moved to outpatient, you have a lot less control over what they're taking or what they're doing.  So as we started to standardize these protocols and study these protocols, I think we got a lot better at identifying how to control pain."

In addition to receiving different medications, patients receive their prescriptions in advance and start taking some medicine before the surgery even begins.

"We have that pre-op visit, we give them all of their prescriptions one to two weeks before surgery, so they can get them filled and go through them and understand what's involved by really holding the bottle and looking at it," Frisch said.  "That way if they have any questions, we can address those in advance."

It's been an adjustment for everyone -- the patients, surgeons, and their staff.

"Most people are actually just used to the old protocols.  They're used to getting Vicodin or Norco or oxycodone, and so when you tell them you're going to have maybe 15 to 30 pills of pain medicine, at first they kind of look at you like you're crazy," Frisch said.

But so far, the results are overwhelmingly positive.

"We get very few calls to refill any pain medication, which is completely different from what it used to be," Frisch said.

"We're about 30 to 40 patients into the study.  We're looking at things like ACL reconstructions, rotator cuff repairs, people that have had a total shoulder," Keller said.  "Our average opioid intake is about a half a pill.  So normally (with) those surgeries you're looking at more -- 30, 40, 50 -- pills and right now we're able to get it down to not even a pill for most patients."

That includes Cox.

"I had absolutely no pain.  I'm thoroughly impressed that I didn't have to touch one opioid.  I mean, I was given prescription of OxyContin.  I didn't even take one of them," Cox said.  "I had less pain after the surgery than before the surgery.  It was pretty amazing."

He hopes the study will encourage other doctors to reconsider their approach to post-surgery pain.

"I think everybody should be trying to get on board with this, and I think it will help a lot of people out," Cox said.  "If it was going to be like this, I wouldn't have put it off for so long."

Keller says it's critical for doctors to play a bigger role in combating the opioid crisis.

"That's great if you can fix a rotator cuff, and they can have less shoulder pain, but if they become addicted to narcotics in the process, they're probably worse than they would've been just living with a rotator cuff tear," Keller said.

The proactive protocol is currently part of a pilot study at Ascension Crittenton Hospital, but from here, Keller and Frisch hope to take it to a multi-center study.    They've already had interest from surgeons in other states.

As a measure of how much they believe in the proactive approach, they're now using it with all of their patients, not just the ones that qualify for the study.