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Join us as we sit down with Amy Baxter, a clinical associate professor of emergency medicine, to explore how societal factors, deceptive marketing, and profit-driven health care systems have contributed to the opioid epidemic. Amy will shed light on the effectiveness of Enhanced Recovery After Surgery (ERAS) and cost-effective non-pharmacological interventions for pain relief. Together, we’ll discuss barriers to adopting opioid-sparing strategies and how policymakers can prioritize solutions to reduce unnecessary post-operative opioid prescriptions.

Amy Baxter is a clinical associate professor of emergency medicine at Augusta University, federally funded for neuromodulation research to reduce needle pain, multimodal low back pain, and opioid reduction.

She discusses the KevinMD article, “How Enhanced Recovery After Surgery solves our opioid problems.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Amy Baxter. She’s a clinical associate professor of emergency medicine, and her KevinMD article today is “How Enhanced Recovery After Surgery solves our opioid problems.” Amy, welcome back to the show.

Amy Baxter: Glad to be here again, thanks for having me.

Kevin Pho: So Amy has been on several times. Go to KevinMD.com/podcast to hear her story and prior episodes. But today let’s jump right into the most recent article, “How Enhanced Recovery After Surgery solves our opioid problems.” Amy, what’s this one about?

Amy Baxter: This is kind of pulling together all of the three previous ones. The basic idea is that people who are exposed to opioids who have certain genetic predispositions are going to get addicted, they’re going to get opioid use disorder. It’s about 6.5 percent on average of all surgeries, whether wisdom teeth or total knee.

And another article was why we don’t pay for options after surgery, and another article was talking about what the reasons were for why we started looking at opioids as a solution instead of other pain management. So this one really brings it all together.

If we don’t prescribe opioids after surgery, then we don’t supply the 3 million new opioid use disorder patients every year. We don’t make it seem safe and comfortable, if a kid’s at a party and they see a pill that happens to be laced with fentanyl but they’re like, ah, this looks like what my parents have around the house, sure, I’ll try it. And, as importantly, we also don’t limit the supply available for people with chronic pain, so they don’t have issues with access, and we’re not fueling the new opioid use disorder flood.

Kevin Pho: So you mentioned the term enhanced recovery after surgery, otherwise known as ERAS. What exactly is that?

Amy Baxter: It’s kind of a moving target. So when it started, the idea was that you don’t need to have opioids after surgery, that actually early movement, alternating ibuprofen and Tylenol, and doing things for comfort, were sufficient to recover. And what they found is that people who get opioids tend to move less, have worse outcomes, they stay on opioids longer, they have more bouncebacks to the emergency room for pain, they really just do more poorly.

So if you want to enhance recovery after surgery, then you need coaching, that somebody can do it without opioids, and also you need a number of different options that’ll get people through the post-op pain better than a pill.

Kevin Pho: In your article you talk about how profit driven health care may play a role in shaping opioid policies after surgery. So talk about that influence.

Amy Baxter: Oh, I mean, the short term is, greed equals death.

We started having a really good biopsychosocial pain program for chronic pain, and then opioids became widespread in the 90s. First it was supposed to be just for post-op pain, and then drug companies were advocating that any kind of pain could be treated with opioids and not have the addiction that you had with heroin. Well, also payers started thinking, why are we paying so much for a biopsychosocial approach to pain management when we could put our chronic pain patients on opioids too? There was no support for this in the literature at all, but it was so much cheaper to pay for opioids than to pay for an approach that was much more the way the body works.

So it’s been perpetuated because of the way that we pay for health care for our seniors, and then that trickles down to what insurance companies pay for. It comes from this 1862 statute, that the precursor of what is now Medicaid and Medicare is supposed to pay for illness, injury, and bodily malformation. And in order for the system not to be bankrupt, they carved out anything for comfort. Currently CMS regards pain management as comfort. So if they say something makes you more comfortable, whether it’s a massage or vibration or cryotherapy, any of these things that have been proven to reduce opioid use, they get out of paying for it by saying it’s comfort. And then the payers do the same.

So I’ve talked to Cigna, UnitedHealthcare, I’ve talked to so many payers, and they won’t pay for things unless CMS does, and CMS is skirting the issue by saying so many pain management solutions are really just for comfort.

Kevin Pho: You could imagine there’s a wide spectrum when it comes to surgery. My question is, is there a role for opioids the more major that surgery is?

Amy Baxter: Yeah. Well, here’s the thing. We think we’ve got one big problem and it’s opioids, and actually we have three opioid problems. We have home pills after surgery, we have the opioid problem of experimentation, and we have the opioid problem of patients with chronic pain who can’t get medications and get suicidal. So all three of these problems can be solved with better pain management after surgery.

Now, the issue of opioids in the hospital is actually a totally different thing, and opioids there are not a problem. So it comes down to the fact that the brain and the way we process pain is very complicated, and opioids do not decrease pain, they cause the dopamine receptors to make you feel pain but you don’t care anymore, because dopamine is such a powerful reward.

Well, in the operating room, in the emergency department, when I was in an ambulance after I broke my neck, those IV opioids, IV fentanyl, IV morphine, those actually reduce chronic pain, they reduce post-traumatic stress, because you’re getting so rewarded that you don’t make the tracks in your brain that associate fear, survival, and pain. So opioids for surgeries are great, they do not lead to opioid use disorder, aka addiction.

This was actually the start of the whole problem, was guys named Porter and Jick in 1980 published a five sentence review of in-hospital opioid use, and they’re like, only four people got addicted, so we’re good. And that’s true, the risk of getting an opioid use disorder in the hospital is very, very small.

What happens is that after about three days of exposure the opioid dopamine receptors involute, they go back in the cell, so they’re resistant to opioids, so that means you need more opioids to get the same effect. Around that time, for most surgeries, people are being discharged home. So they’ve got receptors that are not going to receive the information as well from the opioid, they’re not going to get as much reward. And those people who do have the genetics where they don’t get much of a kick from dopamine normally, so when they get the opioids in this huge rush they feel better than they ever have, so those are the ones who are most likely to get opioid use disorder.

And again, even spinal surgeries, the risk of OUD afterwards is about 10 percent. For total knees it’s 8 to 12, depending on the study you look at. But for wisdom teeth removal it’s 6.8. So it really is a lot more about genetics than what you’re doing.

So, in hospital opioids good. We just need to keep people in the hospital to give them the pain management that they need until they can handle the pain management at home. There’s a bunch of good stuff now. Long acting blocks are really good. There’s research on looking at magnesium and how it complexes with oxytocin to do endogenous pain relief. There are a bunch of other options.

But the quick answer to your question is, yeah, we should not stop using opioids in the hospital, that’s what they’re for. What we should do is realize that oral opioids are going to behave differently and there are better ways to decrease pain.

Kevin Pho: So let’s talk about a common procedure, and you brought up, say, total knee replacements. In your ideal world, after a total knee replacement, what would be the optimal post-op pain regimen?

Amy Baxter: So I would start pre-op, and I would start by giving magnesium a few days before. I would start a month before trying to have the person get stronger, do prehab, so they’re going to be able to move more quickly afterwards. I would supplement with amino acids that would help muscle growth, because a lot of the time these people who are going in for total knees haven’t been exercising, walking, or doing anything because of the pain. So I would give them a pain management device that would include, say, vibration and ice or heat. But I would get them moving before, I would give them magnesium before.

And then intraoperatively there’s some really cool new stuff ablating the pain nerves, so that they are still able to walk afterwards but they don’t have pain from the knee replacement. There are long acting bupivacaine types that will last for a long time. You can do nerve blocks intraoperatively that will decrease pain.

So what’s my ideal post-op? It definitely starts pre-op. And then once they are ready to be discharged, the research shows that if they get up and moving within three hours, so a lot of coaching, in-house support, to get them moving more rapidly. I would also increase water intake, because it turns out if you’re even a little bit dehydrated, pain is increased. This is probably from fascia sticking. There’s about 10 times more pain nerves in fascia that goes over the muscle than in the muscle or the skin itself. So keep them hydrated, that’ll also incentivize them to get up and go use the bathroom.

And then use ibuprofen when a patient can tolerate it, Tylenol, alternate it. And this is the thing that we’re not doing, but this is what ERAS has shown works the best, is having a pain plan and coaching. So if you have people to talk to, that doesn’t flood your system with dopamine, it floods it with serotonin, but it also makes you not care about the pain. If you have family members there, if you’re getting massage, that floods your brain with oxytocin, which doesn’t stop the pain but it makes you not care as much. Playing games, listening to music, those things give you dopamine, which helps you not mind the pain as much.

So all of these answers are because it’s complicated and there’s not one quick fix.

Kevin Pho: Now, to your knowledge, that ideal scenario that you described, is that common practice?

Amy Baxter: Well, common, certainly not. But Vinod Dasa, who’s at LSU, he does total knees, and he lets his patients know that they will not be getting an opioid prescription when they go home, and that is working. And so he is able to get about two-thirds of them home and completing their total knee replacement without having opioids at all.

There’s a really interesting study that looked at ACL reconstruction, and at the time the orthopedist was giving 50 pills and his athletes were using about 25. So we thought, OK, I’m going to write for 30 Percocet, and that way that should cover it, and we won’t have as many leftovers, because a fractional percentage of people don’t store them safely when they have leftover pills. So guess how many pills his athletes then took? 15.

Because the amount of pain was not what was provoking them to take the opioids. It was, I know that this doesn’t feel good and I have something that can make it feel better, but I’m not going to risk taking too many. And if they gave me 50 I’ll take 25, if they gave me 30 I’ll take 15. So guess what, if you give them five, they’ll either take zero or five.

Kevin Pho: Now, whenever this topic comes up, your prior podcasts on KevinMD, it evokes a strong reaction, which I’m sure that you’ve read and felt, right? So what do you say to that counternarrative that the pendulum has swung too far against treating chronic pain, and you have patients who push back pretty hard against that narrative? What’s your reaction to that response?

Amy Baxter: Yeah, they’re absolutely right. I never advocate against giving opioids ad lib, liberally, to people with chronic pain.

I did a TED talk, it now has 1.3 million views, on how your brain hacks pain, and I got all of this push back from the chronic pain, some chronic pain people. But I very carefully carve out, in all of my articles and everything I do, if you’ve got chronic pain and you’re maintained on a stable dose, cool, let that go, that’s fine. If you want to wean, then a lot of these techniques will help, but if you don’t, who cares? Those people are using all of their opioids, they are stably maintained, they are not letting opioids out in circulation, and they rarely overdose. Why do we care? Let them have all the opioids they want.

People misinterpret my desire to decrease post-op opioids and to decrease opioids in circulation as an attack against opioids in chronic pain, and I have always been very careful to carve that out. But again, it’s complicated, and my being pro opioids in the OR and in the emergency room, and pro opioids for pain, gets lost, because it’s simpler just to look at it as a yes, no, opioid binary solution. And it’s just not.

Kevin Pho: So in general, when you propose your path forward when it comes to post-op pain control without opioids, what’s the general reaction that you receive, both from clinicians and patients?

Amy Baxter: It’s a great question. I have a biased sample size, because I work with people who have lost children, I work with people who have become addicted after surgery, and so those family members and those groups are like, you know, smack your head, dumb, of course we should reduce opioids post-op, this is ridiculous.

Now, the whole world, the United States is moving in the direction of the rest of the world. One of my friends, when I was testing my TED talk out on her, she’s in Sweden, and she was like, I mean, it’s a good talk, but it’s sort of irrelevant, I’ve been given one Percocet my whole life and that was for a leg fracture. So they don’t have problems with opioid use disorder, because they’re not giving out something that has a very select group of people that are going to be highly impacted.

What’s most interesting is, the people who give me the most push back are people who have a little brown yellow canister of pills in their drawer, and every now and then they take one, and so they don’t want to lose access. But they also don’t want to lose face, they don’t want to say, yeah, sometimes I just feel bad enough that I really just need a little reward.

And it’s pain. I mean, I too, you know, I’ve broken my neck, I’ve ripped my shoulder, I think I’ve broken 11 bones over the course of my life, and pretty much all in separate instances. So I certainly understand the feeling of pain and just wishing you could go to sleep, and I’m OK with that. But what is interesting is, push back often is, I have times that I really wanted an opioid and I don’t want to lose that. And that’s a bit disingenuous to me.

Kevin Pho: So you mentioned Sweden. So talk about that cultural difference here in the United States. Perhaps, are you implying that there’s more of an inclination towards using and prescribing opioids versus the rest of the world?

Amy Baxter: Kevin, Kevin, it’s not just opioids. When I go to see our friends in the Czech Republic, they all laugh at how many pills we bring with us. And as physicians, I think we’re not inclined to bring many pills or to take pills, we’re often more anti-medicine than non-physicians. But in other countries they’re not taking antihistamines on a regular basis, they’re not taking Adderall, they’re not taking ibuprofen whenever they have a headache. They’re not taking pills in general.

And it is because our system, this Medicaid and Medicare, reimburses pills. We will pay for any pill that gets through the FDA. If you have a device that gets through the FDA, it’s going to be termed for comfort and it’s not going to get paid for. We’re one of two countries where pills can be advertised directly to patients on mainstream television. We and New Zealand are the only places where Pharma companies are allowed to advertise. So we are a quick fix pill country.

It starts in childhood. I was talking to a friend of mine at the FDA, there’s a company that wants to make another over-the-counter pain reliever besides ibuprofen for children, and I was like, the thing is, if we make children grow up thinking, if I hurt I need a pill, why do we expect they’re going to be intimidated by a pill when they get to a party in adolescence? Why do we think that they’re not going to think, I just need to move around, I just need to get up, I need to drink more water, I need to have magnesium?

We are a very pill oriented culture, and that does lead me to an idea for how we could pay for some of the things we don’t pay for now.

Kevin Pho: We’re talking to Amy Baxter, clinical associate professor of emergency medicine. Today’s KevinMD article is “How Enhanced Recovery After Surgery solves our opioid problems.” Amy, we’ll end, as always, with your take-home messages to the KevinMD audience.

Amy Baxter: My take-home message is, we capitate services for orthopedics. What if we capitated lifetime pharmaceutical costs, so that pills then had to be provided by the manufacturers that have already made their profit on it?

What if, when we have $13 billion going to Eliquis, which is a blood thinner, and that’s the number one biggest thing Medicaid, Medicare pays for, those medications may be 5 percent better than warfarin or Coumadin, so what if we only let doctors write for 5 percent more of their scripts for those problems? For the really expensive drug, maybe 10 percent. I mean, I’m absolutely opposed to pre-authorizations, it’s ridiculous and time consuming, but we do have both the money and the understanding and the science in our system to solve these problems. It’s only that we need to stand up for making common sense rules and laws that allow our patients to get better, and that we pay for what is going to promote health and not addiction.

Kevin Pho: Amy, as always, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.

Amy Baxter: Thank you.