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How nerve blocks are reducing opioid use in Northwell ORs
Through the use of nerve blocks, these doctors can limit patients' reliance on opioids following surgery
America has an opioid problem. No matter which metric you look at — overdose rates, addiction rates — the problem seems to be getting worse. Since 1999, over 760,000 Americans have died from a drug overdose. In 2018, two out of three of those deaths involved opioids, making opioids a leading cause of death in the U.S.
While there are myriad reasons people become addicted to opioids, one is opioid use during and after surgery. One in five patients is still using opioids three months after surgery, and 3%-4% become chronic users. But what if doctors didn’t have to prescribe opioids after surgery to manage pain? One surgery team at Northwell Health, led by Dominick Gadaleta, MD, chair of surgery at South Shore University Hospital and David Pechman, MD, bariatric surgeon at South Shore University Hospital, decided to find out.
“Several years ago, I was asked as part of a team to help shorten length of stay and to see what the barriers were,” Dr. Gadaleta recalled in a recent episode of Northwell’s podcast, 20-Minute Health Talk. “What we all quickly learned was that the things that we were doing to the patient were part of the barriers to recovery. And as it turns out, one of the most important things besides innovative surgical techniques is the elimination of opioids. This led to a concept of enhanced recovery, which was going on in Europe. We quickly adapted it to our program at NSUH.”
Using an innovative pain management technique called nerve blocks, Drs. Gadaleta and Pechman have turned the status quo of bariatric surgery on its head. No longer are patients requiring long recoveries in hospital or being prescribed 15-30 opioids to manage pain. Now, patients recover quickly and only need traditional acetaminophen (Tylenol) to mitigate the painful side effects of surgery. Gone are the troubling side effects of opioids and the risk of addiction. It’s a transition that will most certainly save lives.
“What we saw when we ceased prescribing opioids to manage postoperative pain,” said Dr. Gadaleta, “was shorter length of stay, quicker recovery and better patient satisfaction.”
This surgical team's deployment of nerve blocks is part of a larger effort at Northwell Health to reduce opioid use in ORs, as well as in the emergency room. Led by Northwell's senior vice president of anesthesia, Joseph Marino, MD, the team at Staten Island University Hospital were the first in the system to use a femoral nerve block in their emergency rooms (ER) in 2022.
While these innovative approaches to reducing reliance on opioids and improving the way medical teams manage a patient's pain, nerve blocks themselves aren’t new. Most people have heard of an epidural, a type of neuraxial nerve block commonly used during childbirth. Along with traditional anesthesia, nerve blocks have been used in various capacities since 1885 when American surgical pioneer William Stewart Halsted invented them by injecting cocaine into the nerve trunk.
Nerve blocks act like a local anesthetic, numbing the nerves at a specific site for a specific amount of time. For example, using a nerve block at the site of a surgical incision prevents pain in the immediate aftermath of a procedure. Because pain doesn’t last forever ― it lessens every hour after surgery ― nerve blocks give patients a head start on recovery. The result is wonderfully effective: by preventing pain at the nerve site, a patient requires less pain management. As the nerve block gradually wears off, the pain threshold is greatly reduced from its apex. Instead of requiring Percocet or other opioids to manage the pain, many patients can now recover with over-the-counter pain medications such as acetaminophen or ibuprofen, completely eliminating the need for opioids.
Dr. Pechman was quick to point out that ditching opioids in the OR doesn’t mean patients are left to white-knuckle through their pain post-op. “We’re not withholding medication that the patients need,” said Dr. Pechman on the same 20-Minute Health Talk episode. “We do such a good job of multimodal pain therapy that the patients do not need those medications. And then if we can avoid the downstream effects of slower bowel motility, some patients will experience severe nausea or itchiness. Little things like that can become big things, then cause other issues. So if we can really eliminate all those downstream problems and let patients spend less time in the hospital and feel better, it’s really a win-win.”
At South Shore University Hospital, the transition away from opioids is spreading from bariatric surgeries to C-sections to ultrasound-guided usage in emergency departments. Like many successful innovations, it began with a change in perspective. Opioids treated a symptom; nerve blocks address the cause.
“Understanding basic anatomy and where the pain comes from is really the first key,” said Dr. Gadaleta of the shift. “If we can block pain and we do this with our anesthesia colleagues at its source at the nerve level, the patient does not experience pain. But the other thing is to have your colleagues, nursing staff and the entire team including the patient understand what pain really is. And it turns out we were treating other conditions with pain medication and oftentimes the opioids were making the conditions we were trying to treat worse.”
Dr. Gadaleta describes a common scenario in which a patient experienced bloating caused by the body’s natural stress response to surgery. Opioids were typically prescribed to address the pain caused by the bloating, but instead of helping, opioids increased the patient’s suffering.
Using nerve blocks in addition to preemptive medications goes a long way toward eliminating the pain before it starts by addressing it at its root cause.
The transition away from opioids at South Shore University Hospital has been swift and effective. After the program’s implementation in the bariatric program less than three years ago, the number of opioids used postoperatively fell to nearly zero within a couple of months. Now Dr. Pechman describes the presence of opioids as “virtually absent.”
From a patient perspective, the fact that the opioid epidemic has touched lives across all sectors of American life has made this transition to alternative pain management most welcome.
“Patients are really happy to hear that they will not need opiates in our program,” said Dr. Pechman. This is great news for Northwell patients, but Dr. Gadaleta isn’t satisfied.
To scale the program at a national level will require a multifaceted approach that includes awareness campaigns for patients and education at all levels of nursing and medical schools, as well as the expansion of pilot programs across the nation’s health care systems.
Yet Dr. Gadaleta is quick to point out that even the smallest reduction in the use of opioids has positive implications. For example, patients with chronic pain may come to the hospital using opioids.
Using nerve blocks during surgery may not eliminate their opioid use, but leaving the hospital without increasing usage is still a win. “Even if we can get the number of opioids prescribed from 30 to five, I think we’re doing good work,” said Dr. Gadaleta. “We can’t discourage people that need that crutch, but I want to see the day where it’s zero across the board.”
Related news
New applications of anesthesia have revolutionized the field of pain management and are part of an important and necessary shift away from opioid use.
Local and state officials collaborate with clinicians to create strategies to fight opioid abuse on Staten Island.
Northwell Health’s “Pathways to Recovery” program, which leverages the health system’s emergency departments to help those struggling with opioid and substance use disorders.