Opioid abuse — as you know — has now become a national crisis, with the Centers for Disease Control and Prevention estimating a $78.5 billion annual burden on the American economy. What can be done?
Advancing better practices for pain management is a key strategy in the U.S. Department of Health and Human Services’ (HHS) plan for addressing this epidemic. This is where healthcare providers come in. If we can start our patients along a track that does not include the heavy use of opioids for pain management, we can be a part of the solution.
Those of us in the medical field need to help our patients manage pain in a way that is both effective and responsible. As you already know, a multimodal pain approach includes opiates, regional anesthesia and non-opiates used to treat pain such as NSAIDS (non-steroidal anti-inflammatory drugs) and Tylenol.
This multimodal approach decreases the burden or amount of opiates needed during the peri-operative and post-operative period., While our approach must sometimes include opioids — used carefully and mindfully — we can also make use of the many other available methods of pain relief, such as individual and regional nerve blocks.
And the good news is that recent technological innovations in regional anesthesia may be opening up the pathway to further minimize opioid use and potential, subsequent opioid dependence. Here’s how.
A Brief History of Ultrasound-Guided Regional Anesthesia
Within the American medical field, femoral nerve blocks first appeared in the literature in 1952, while ultrasound guidance first appeared in 1989 (for an axillary block). Ultrasound was referenced with increasing frequency for femoral nerve blocks beginning in 2006, and has steadily increased ever since. The technological invention, ultrasonography (US), has allowed regional anesthesia to continue to advance.
“Ultrasonography (US) as a means to guide peripheral nerve blockade (PNB) was first explored by anesthesiologists at the University of Vienna in the mid-1990s. Although radiologists had made use of ultrasound technology to guide needles for biopsy, the application of this imaging modality for PNB was novel at that time.”
Technological Advances Within Regional Nerve Blocks
From there, according to the New York School of Regional Anesthesia, Canadian practitioners at The University of Toronto embraced this technology, “further demonstrating its utility and describing in detail the sonoanatomy of the brachial plexus.” At the same time, more advances in technology were occurring, such as the invention of needle recognition software, smaller and more mobile ultrasound platforms, and improved resolution. All of these advances have since led to the increased use of ultrasound-guided regional anesthesia (USGRA) by anesthesiologists today.
Ultrasound guidance offers a number of important practical advantages for nerve blockade. With USGRA, for example, anesthesiologists are able to better visualize “the anatomy of the region of interest,” which “results in more informed guidance for the needle pathway.” Additionally, through real-time ultrasound imaging, the delivery of the anesthetic can be seen, and real-time adjustments of the needle tip can be made to aid in distribution of the anesthetic.
Why is this important in combatting the opioid epidemic? Well, as noted in “Advances in regional anesthesia: A review of current practice, newer techniques and outcomes,” research has shown that paravertebral blocks can result in better post-operative analgesia with decreased opioid consumption decreased length of stay and decreased related side effects compared to patient-controlled analgesia. A prospective observational study of patients undergoing major breast surgery under general anesthesia showed that a single T4 PVB resulted in significantly decreased dynamic and movement pain scores at rest up to 6 h post-operatively, and decreased opioid consumption.
Please note that paravertebral nerve blocks are just one example of many where there implementation has decreased pain scores, length of stay, and more. There, multimodal pain approaches have been successfully used in many orthopedic procedures and resulted in many surgeries moved to outpatient surgery centers since pain and many of the negative side effects associated with opiate use were no longer an issue.
Also, regional anesthesia is frequently used in the form of chronic pain blocks. There are multiple procedures that range from epidural injections (for pain involving the neck and arm or the back and leg), facet injections (into the joints that allow movement of the neck and back) and injections for burning pain of the arms or legs due to a syndrome called Complex Regional Pain Syndrome or Reflex Sympathetic Dystrophy (CRPS).
Due to significant advancements in ultrasound technology over the past 10 years, the practice of regional nerve blocks has made great strides. Today, regional anesthesia is used significantly in:
– Chest wall surgery
– Shoulder surgery
– Orthopedic surgery
– Obstetrics and C-sections
– Abdominal wall surgery, and more
What Does the Future Hold for Regional Techniques?
One of the earliest case studies examined the use of opioids versus regional anesthetic analgesia, and showed promising results; but then, along came conflicting data from a myriad of studies making similar comparisons.
Today, the data has shown that regional anesthesia is effective for the adequate management of acute pain. What we still don’t know is this: Does regional anesthesia have a beneficial effect on the development of chronic pain? It’s still too soon to tell.
Conclusion
Today, while we are not avoiding the use of opioids in patient care, we should be monitoring and selectively administering opioids and, where possible, deploying regional techniques. Perhaps, as ultrasound-guided regional anesthesia technology continues to advance, we can continue to combat the opioid epidemic from our surgical rooms and in our approach to responsible post-op patient care.
About Dr. Armen Chalian
Dr. Armen Chalian M.D. is an Allied Anesthesiologist specializing in adult and pediatric anesthesia. Dr. Chalian attended medical school at UCLA and did his residency at the University of Southern California Medical Center. He joined Allied Anesthesia in 1993; since then, he has handled more than 20,000 cases there. Dr. Chalian currently specializes in anesthesiology for pediatric, obstetric, neurology and orthopedic patients, as well as chronic pain management. Previously, he specialized in anesthesia for pediatric and adult open-heart surgery.
