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Posted July 19, 2021
Listen to this episode of the Healthy Vitals Podcast.
Dr. Kiel Pfefferle discusses how Summa Health is moving away from opioids and narcotics as the primary pain relief after joint replacement surgery.
Scott Webb: Narcotics and opioids were commonly prescribed for pain relief following surgeries in the past. But due to high addiction rates and the opioid epidemic, alternate pain relief strategies were needed. And joining me today to tell us how minimally invasive surgical techniques and the new pain ball system are helping to reduce the need for opioids is Dr. Kiel Pfefferle. He's an orthopedic surgeon at Summa Health.
This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Doctor, thanks so much for your time today. I want to have you start by helping listeners to understand how and why opioids became such an epidemic.
Dr. Kiel Pfefferle: Yeah, absolutely. Thanks for having me on. You know, as a hip and knee surgeon, the traditional way we used to treat pain control preoperatively and postoperatively was with opioids. And when I trained in residency, which is not so long ago, we would just order morphine and say, "Give as much as you can until they have a severe side effect." There's vomiting or confusion or delirium.
What we found is that then patients ended up becoming addicted to those narcotics, when those were our only lines of treatment for pain control. And then, we were being judged on our ability to control pain. And with that being our only option, we found that patients were having severe side effects.
Scott Webb: Yeah, I wanted to talk about that. Let's talk a little bit about the side effects and then ultimately why are they so deadly, like why is this epidemic such a problem?
Dr. Kiel Pfefferle: Yeah, the side effects that we see, you know, commonly, the milder side effects, things like nausea and vomiting, and sometimes in severe cases that can be worse than pain, as well as constipation, confusion, which can lead to falls and fracture in some of my patients if they have falls, and then, addiction as well.
And we've actually found that patients who are on opioids preoperatively have a higher chance of having severe pain or uncontrollable pain post-operatively and long-term pain, because their body is kind of revved up and they've built up a tolerance to the opioids. So we've also found longer chances of long-term pain. And then the addictive potential, they're related to heroin. So what we saw was that as we decrease our prescriptions of opioids, it became harder and harder to get in patients who were addicted, end up turning to illegal drugs, things like heroin or fentanyl. And then the overdose potential is very high, especially when you're using something as potent as a fentanyl when it's not used in a controlled manner. And then that decreases your respiratory drive or your body's desire to breathe in an overdose. That's what happens, leading to potential death.
Scott Webb: Yeah, definitely. And as you say, opioids are what you guys had, and you were in the business of, you know, performing surgery and treating people's pain. So it's what you had, it's what you used. Are there some other things that have been used preoperatively or postoperatively, you know, before and after surgery that has been sort of the traditional way things have been done?
Dr. Kiel Pfefferle: Yeah, so things like Tylenol and anti-inflammatories, both preoperatively and postoperatively. And then there are cortisone injections, physical therapy, icing the knee or hip and those modalities preoperatively. And now with some really strong data that show that opioids do not help in long-term arthritis control, we've really stopped using them preoperatively, which I think has really helped.
Scott Webb: Are there less side effects when you use local anesthetics in surgery? And if so, why?
Dr. Kiel Pfefferle: Yeah, absolutely. So using what I like to call multimodal pain control is what we have coined it now is using multiple different drugs at low doses to help with pain control. And then we can avoid the side effects at high doses, but still have some effects. And the local anesthesia that we use, things like injections and periarticular, injections and a pain pump can help tremendously. We don't see the systemic side effects such as nausea, vomiting, urinary retention, addiction potential, confusion or altered mental status. So it's been a huge improvement in our ability to control pain locally.
Scott Webb: That's good to hear. And I think that maybe one of the reasons or some of the reasons why, you know, folks kind of suffer, you know, their quality of life suffers and they don't have these sort of elective surgeries, if you will, simply because they're worried about the pain, they're worried about the side effects. And I know one of the things you're doing there at Summa Health, which sounds pretty revolutionary, using this ON-Q pain relief system. So doctor, tell us about the pain ball. What is that?
Dr. Kiel Pfefferle: Yeah. For our knee procedures and then some of our foot and ankle and shoulder procedures, we've worked pretty hard with anesthesia to work on where we used to do a one-time nerve block that would last about 24 hours, we were finding patients would go home, they'd feel great. And then the block would wear off and have this rebound pain. And, you know, we were really looking for something that would last longer than 24 hours. Now, it is similar to an IV that goes in and for the knees, it goes in right after the nerves give off supply to the quadricep muscle, but then the pain fibers to the knee are then numb. So you still have full motion control and full control of your knee. But the pain fibers are numbed around the knee. And so that helps tremendously. And it lasts for about five days and it's patient controlled. So right before therapy or if they're having pain, they can turn it up. And once their pain is controlled, they can turn it down and save some of the medicine and we found, you know, lasting up to five days at this point. And so patients who've had that versus patients who had it the traditional way, they'll tell me it's a game changer in the amount of pain they can have, and that it's been a godsend to them.
Scott Webb: That's amazing. And I'm sure there's some other benefits as well, maybe earlier release from the hospital, able to return to daily activities more quickly, maybe you could speak to those things as well.
Dr. Kiel Pfefferle: Absolutely. This has given me a lot of confidence to perform outpatient total knees, where just not too long ago, patients were staying three to seven days in the hospital and then go into a nursing home. I have many patients who go home the same day of surgery, they'll walk in the stairwell, and then go home. And this gives me the confidence they're going to go home and their pain's going to be controlled and have a restful night's sleep. I think it also allows for them to get better range of motion more quickly. They're not having as much pain that's hindering their motion in participation in therapy, and it really gives them the confidence that they're going to be able to recover.
Scott Webb: Yeah, I'm sure it does. And probably it helps them get to PT more quickly as well.
Dr. Kiel Pfefferle: Absolutely.
Scott Webb: That's great. I want to give you a chance to kind of toot your own horn a little bit. I know that you do anterior hip replacements and outpatient joint replacement that you've been discussing here today, total knees and so on. So maybe just tell folks a little bit about your approach to doing these types of surgeries, where you do them, how you do them, recovery times and so on.
Dr. Kiel Pfefferle: Yeah. On the hip replacement side, I perform basically hip and knee replacements. And on the hip replacement side, and the majority of my hip replacements are performed through an anterior approach, which means for the patient less pain, less muscle damage, faster recovery and less chance of it dislocating. And for me, it allows me to use an x-ray machine in the operating room to more precisely place the components, which I think benefits the patient in the long run for longevity of the component. And this has allowed patients to walk the day of surgery. And again, many go home the same day of surgery, if they're a candidate for that, or the day after surgery. Rarely are patients having to go to nursing homes anymore. That most are going home, walking with a walker or a cane for one to two weeks. And then usually by the time I see him back in four weeks, they're not using any assistive device.
I think through our minimally invasive approaches and our multimodal pain control and our work with the anesthesia group, we've really come a long way in the ability to control pain. So patients can come to get surgery to get better and not have to worry about the amount of pain they're going to be in and the recovery process.
Scott Webb: Yeah. It's really amazing how far things have come. My mom had a total knee and, you know, she was up walking around a few hours later and I was like, "Wait, you're walking in the hospital?" She said, "Yup. I'm walking around." Still wasn't out of the weeds, obviously. There was pain and trying to relieve that pain and get ready for physical therapy and all of that, but it is really, truly amazing. And the minimally invasive approach, it seems to be what everybody wants. It's such a buzz in medicine right now, but it's smaller scars, faster recovery times, less medications to treat pain, right? There's a lot of benefits to minimally invasive.
Dr. Kiel Pfefferle: Absolutely. Yeah. It's such a pleasure to see someone who is having trouble even going the grocery store, get up and walk and smile that day or the next day and know that they're going to get their life back.
Scott Webb: Yeah, no doubt. Well, doctor, this has been really educational today. And as we wrap up here, any final takeaways, whether it's the pain ball system or anything else? You know, we've talked about kind of the past and how we're trying to eliminate narcotics and opioids and the future maybe is this pain ball system. So, final takeaways.
Dr. Kiel Pfefferle: I think we're going to continue to fine tune our ability to control pain and select the correct patients to go home the same day. Or there are some patients that will need to stay maybe one or two days depending on their preoperative status. But I don't think patients should fear pain and surgery is not always our first step. So if they're having pain, they could seek out their local orthopedic surgeon and see what we have to offer for them.
Scott Webb: That's a great point. Yeah, we didn't touch on that, but that is such a great point that surgery is for most surgeons, ironically maybe, the last resort, that lots of things are tried beforehand, pain management, physical therapy, and so on. And then maybe you get to surgery and good to know, that pain relief is really not something that people should worry about as much anymore. So doctor, thanks so much for your time today and you stay well.
Dr. Kiel Pfefferle: Thank you.
Scott Webb: For more information, go tosummahealth.org/orthopedic. And if you found this podcast to be helpful and informative, please share it on your social channels and check out the entire podcast library for additional topics. This is Healthy Vitals, a podcast from Summa Health. I'm Scott Webb. Stay well, and we'll talk again next time.