Sundar Rajendran, MD
Anesthesiologist, Colorado Springs, CO
What postsurgical pain therapies and medications do you prescribe for your patients?
Our practice has moved towards using continuous peripheral nerve block (CPNB) with home infusion for most extremity orthopedic cases that would typically receive more than 10–20 prescription pain medications. Orthopedists are the highest prescribers of opioids because surgery involving bone work is very painful. CPNB is perfectly suited for most of these procedures.
CPNB can often make a more painful procedure easily managed with minimal opioids. Once CPNB became fast, easy and effective to perform by all of our providers, it has become our first-line choice for postop pain control.
What, in your opinion, are the primary obstacles to eliminating the use of opioids in postsurgical pain management?
I think there are several obstacles to reducing opioid use. The main one has been in finding an alternative that is considered as good if not better. We know CPNB is significantly better, but convincing providers that CPNB is feasible and practical has been a challenge because historically CPNB was complicated to perform and time consuming to fit well into a surgical schedule. Now that we have a device and method that can easily and quickly be performed by most anesthesiologists, the obstacle has become covering the cost for the pump and supplies.
We need to get payers to realize that the cost associated with home infusion is a fraction of the cost associated with opioids and its associated complications. If we can get the cost covered for using CPNB home infusions, there is no reason why it cannot replace opioids as the primary source of pain control in orthopedic surgery. CMS will pay for home infusion pumps for pain control only if they use morphine, but not if they use local anesthetics. The incentive needs to be implemented to cover the cost and encourage more CPNB rather than hinder its use.
Patient satisfaction with surgical procedures is often heavily dependent on their level of postsurgical pain. Do we need to reset patient expectations regarding postsurgical pain or do you believe alternative therapies can achieve the same satisfaction as prescription opioids?
I believe we need to reset patients’ mindset from thinking opioids are the best form of pain management. CPNB is a far superior form of pain control with many benefits, and patient satisfaction with CPNB is consistently leaps and bounds higher than with opioid-based pain control. The goal should be to provide the best pain control possible because postop pain can impact recovery in many untoward ways that add to cost and suffering.
How would you assess current state and federal efforts to reduce opioid addiction?
Clearly, efforts to address the opioid crisis have been successful in getting the word out and making the public aware. There has also been some success in increasing access to treatment and recovery; however, not enough has been focused on preventive efforts. It is essential to stop the number of people getting addicted in the first place or else it will overwhelm the system on the backend. Eliminating all pain meds is not an option, and using lesser pain meds for painful procedures will also not be effective. The answer is to use multimodal approaches but encourage better options for non-narcotic pain control such as CPNB.
You have been actively involved with the Coalition for Prevention, Addiction Education, and Recovery (CPAR) in Colorado, as well as the Colorado Consortium for Prescription Drug Abuse Prevention. Can you briefly share with us a couple of your success stories?
With the development of a simpler CPNB method and a newly approved Food and Drug Administration device, we have been able to reduce opioid use to an extent greater than we would have thought. We now employ CPNB on all of our shoulder arthroscopy patients as well as all knee, ankle, foot and hand surgeries. Furthermore, we have seen many patients tell us they never took even one opioid for their entire recovery period. CPAR and the Consortium were instrumental in helping the new device receive state funding to advance the development. They are also working to help start a pilot program with a major payer evaluating the benefits of reimbursing CPNB as well as recruiting worker’s compensation payers to participate.
Conflict of Interest Declaration: Dr. Rajendran is a cofounder of a company that manufactures a specialized catheter that facilitates CPNB. He and his partner created the company specifically to develop this catheter.