Category Archives: Pain Medicine

Anesthesiology, Medical Education, Pain Medicine, Regional Anesthesiology

Why this is a great time to pursue a career in regional anesthesia

When you start saying “Back when I was in training…”, you are officially old.

Well, back when I was in training, I didn’t think regional anesthesia was a career path. We weren’t using ultrasound yet, and catheters were still experimental. Regional anesthesia was just part of anesthesiology, and there was a fairly limited set of blocks to offer patients. Besides spinals and epidurals, I was fortunate to learn how to do more peripheral techniques than most residents in my cohort: the femoral nerve block; proximal and distal sciatic nerve block; brachial plexus blocks (interscalene, infraclavicular, and axillary); and paravertebral block. All of these blocks were performed using landmarks to guide needle placement, and we used indirect needle tip position endpoints for confirmation (e.g. nerve stimulation or paresthesia).

Fast forward to today, and the subspecialty field of regional anesthesia and acute pain medicine (RAAPM) has exploded! The demand for better perioperative pain control that doesn’t depend solely on opioids has driven the development of advanced clinical fellowships in RAAPM for anesthesiologists who want to become acute pain medicine experts. A consortium of 14 medical organizations representing anesthesiology, pain medicine, surgical specialties, and hospitals has unanimously agreed on a set of principles to guide acute perioperative pain management, and included in these principles is access to a pain medicine specialist and the employment of multimodal analgesia with regional anesthesia techniques when indicated.

What does this mean for medical students and anesthesiology residents who are thinking about their careers? The future of RAAPM is bright! Considering that physicians work for about 30 years or more after completion of training, it’s really important to find a specialty, and even a subspecialty, that: 1) allows you to take good care of patients and be the kind of doctor you’ve been called to be; and 2) continues to evolve in innovative ways so you can keep learning new and exciting things.

I’ve written before about how much I love being an anesthesiologist, but I really love being a RAAPM subspecialist! There is nothing more satisfying than preventing and treating pain for patients who are undergoing surgery or suffering from traumatic injury. Today’s RAAPM fellowship curriculum trains anesthesiology residency graduates over the course of one year to become leaders with the knowledge and skills to perform a wide range of advanced procedures and manage acute pain services in any practice setting. New procedures to extend the benefits of regional analgesia beyond the first few postoperative days are currently being studied, as are new models of care such as transitional pain services that can add significant value to healthcare systems.

After fellowship is over, you join an incredible worldwide community of RAAPM experts who will support and mentor you throughout your career. Conferences feel like family reunions, and the leaders in the field whom you’ve looked up to become your friends.

To learn more about our RAAPM fellowship at Stanford, please visit our website. Information on other programs is available through ASRA Pain Medicine.

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Anesthesiology, California Society of Anesthesiologists, Healthcare, Leadership, Pain Medicine, Patient Safety

My Last Update as CSA President

It is hard to believe, but this is my last report as CSA President!

We recently held our CSA annual meeting in San Diego which was organized by annual meeting Chair Dr. Christina Menor. This meeting had a theme of “CSA Connect” and was designed to promote more interactive discussion within committees, opportunities to network and catch up with friends and colleagues, meet new people, and enjoy some time to relax.  I think this meeting achieved all of these objectives!  I have listed a few of my personal highlights and takeaways below.

Annual meeting Vice-Chair Dr. Engy Said put together a fantastic point-of-care ultrasound and regional anesthesia workshop on Thursday.  We held very active committee meetings from noon until almost 10 pm (for those on the GASPAC Board), and it was great to see so many members participating in person and virtually thanks to the two new Owl Labs meeting cameras that we recently purchased for CSA.  We had a number of special guests in attendance at the annual meeting including past CSA Presidents, one of whom is also our current ASA President Dr. Michael Champeau!  We also had the President of the New York State Society of Anesthesiologists, Dr. Jason Lok, and Dr. John Fiadjoe, Executive Vice Chair of Anesthesia at Boston Children’s Hospital and Director of the American Board of Anesthesiology, joining us at the conference. 

On Friday, Dr. Cesar Padilla from Stanford gave a compelling presentation on his project to develop and promote Spanish language patient educational video content through a joint venture between Stanford and YouTube.  He then introduced our keynote speaker, California Surgeon General Dr. Diana Ramos, who discussed the work being done in California to decrease maternal morbidity and mortality and how we as anesthesiologists can be leaders in this domain.  We had so many talented speakers from multiple institutions throughout the state who presented on various topics relevant to anesthesiology, critical care and perioperative medicine, and pain management.  After the end of the day’s programming, we had a fantastic networking reception, which Dr. Ron Pearl kicked off as the first of our 75th Anniversary events. 

I gave out the first annual CSA President’s Impact Awards to recognize CSA members for the amazing work they are doing.  Here are the winners!

  • Educator of the Year: Dr. Sophia Poorsattar, UCLA
  • Physician Advocate of the Year: Dr. Todd Primack, Vituity
  • Clinical Innovator of the Year: Dr. Arash Motamed, USC
  • Rising Star: Dr. John Patton, UCLA
  • In-Training Physician of the Year: Dr. Abbey Smith, UC Davis

CSA President-Elect Dr. Tony Hernandez Conte led off the Saturday session with an overview of advocacy efforts by CSA and current legislative issues affecting anesthesiology and pain medicine.  Then I had the privilege of introducing our honorary CSA Leffingwell Lecturer, Dr. Linda Mason, who has been one of my most influential mentors and sponsors.  She is a true icon in our specialty and a role model.  Her advice about a career not being a straight line, “There are squiggly lines too,” resonated with so many attendees.  She even provided her own assessment of the top 10 challenges facing women in leadership and gave some advice about how to be successful.  For anyone interested in hearing more from Dr. Mason as well as some other inspirational anesthesiologists, see these video interviews posted by Dr. Allison Fernandez for the Women of Impact in Anesthesiology project.

Attendees for the annual meeting even stayed until the end on Sunday!  We had great talks on patient safety and communications, diversity and inclusion, pain management, and regional anesthesia.  Then those of us on the Board of Directors closed out the meeting weekend with a very productive session with a fair amount of debate and discussion that will result in some action items for this June House of Delegates.

What else has CSA been up to in recent months?

The CSA website task force has been working closely with website and brand marketing experts to completely redesign the CSA website to make it faster, reflective of the society, and responsive to member needs. The task force is on track to launch the new website by June.

The CSA Communications Committee, chaired by Dr. Emily Methangkool and in partnership with KP Public Affairs, has increased its production of high quality content in a variety of formats, from social media to print media, to promote the value of anesthesiologists’ work and the profession of anesthesiology. Check out recent CSA Vital Times podcast episodes on perioperative work culture and a special interview with Dr. Sharon Ashley in honor of Black History Month in February. The CSA Online First blog posts new content every week! Recent posts have featured CSA members’ activities in research, clinical informatics and global health and member profiles of CSA’s women leaders during the Women’s History Month Spotlight series in March. The CSA Vital Times magazine under the editorship of Dr. Rita Agarwal has produced another fantastic issue that is full of society updates, highlights from each anesthesiology residency program in California, and special articles by CSA members on artificial intelligence, global engagement, Project Lead the Way and other community outreach programs, and the history of anesthesiology in recognition of the contributions of California’s anesthesiologists during this Diamond Jubilee 75th anniversary year.

The week of January 29 through February 4 was designated Physician Anesthesiologists Week in California by an unanimous vote in the Assembly. Assemblymember Matt Haney presented Assembly Concurrent Resolution 3 from the floor, stating that “Anesthesiologists are guardians of patient safety in the operating room, in the delivery room, in the intensive care unit, in pain management clinics, and on the frontlines of the COVID-19 pandemic. They are an essential profession in the healthcare industry. For their dedication to their patients, it is our honor to recognize them for the work they do to care for us.”

So what’s to come between now and the end of my term as President?  We continue to work our legislative contacts to advance our advocacy efforts.  We are developing more digital image and video content to highlight the importance of anesthesiologists in improving patient experience and outcomes over the course of history and in the present.  We are promoting the next CSA annual meeting to be held at the Disneyland Hotel next April 4-7, 2024.  We are preparing for the end of the academic year and are promoting the early career membership program for CSA and ASA to keep our soon-to-be graduates engaged in organized medicine. 

I cannot be more excited for the upcoming governance year as Dr. Tony Hernandez Conte takes over as President.  He has been a fantastic partner this year, and I have learned so much from him.  As I wrap up, I will conclude by saying again how proud I am of all the work we have accomplished in advancing the mission of the society this past year. We have stayed true to our identity as an organization representing the great specialty of anesthesiology, anesthesiologists in California, and our patients.  I wish to thank to all of our CSA physician volunteers, association management staff members (especially Dave Butler, Megan MacNee, Rachel Hickerson, Dena Silva, Evan Wise, Denise King, Kate Peyser, and Jonathan Flom who got frequent messages from me all year), Alison MacLeod at KP Public Affairs and Bryce Docherty at TDG Strategies on behalf of CSA for the tremendous amount of personal effort and dedication that it takes to keep this organization mission-focused and moving forward.

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Anesthesiology, Pain Medicine, Regional Anesthesiology

Resetting the Bar for Acute Perioperative Pain Management

Despite previously published guidelines and practice recommendations, there remains unwarranted variation in the quality of pain management provided to patients having surgery. Unwarranted variations in healthcare are inconsistencies in clinical practice that have no basis in science or patient preference.

In 2019, the U.S. Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force published its report, which called on medical societies to work together to develop evidence-based guidelines to improve the quality of pain care delivery. The Task Force, which was Chaired by Stanford anesthesiology and pain medicine specialist Dr. Vanila Singh when she was Chief Medical Officer of HSS, recommended individualized, multimodal, and multidisciplinary approaches to pain management to help decrease an over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders.

Following the release of this Task Force report, leaders of the American Society of Anesthesiologists (ASA) decided to take action and launched a 2-year project. As Chair of the ASA Committee on Regional Anesthesia and Pain Medicine, I participated as a member of the steering committee and served as Co-Chair of the Pain Summit. ASA invited 13 other medical societies to join a new consortium dedicated to improving pain management (in alphabetical order):

  • American Academy of Orthopaedic Surgeons
  • American Academy of Otolaryngology-Head and Neck Surgery
  • American Association of Neurological Surgeons
  • American Association of Oral and Maxillofacial Surgeons
  • American College of Obstetricians and Gynecologists
  • American College of Surgeons
  • American Hospital Association
  • American Medical Association
  • American Society of Breast Surgeons
  • American Society of Plastic Surgeons
  • American Society of Regional Anesthesia and Pain Medicine
  • American Urological Association
  • Society of Thoracic Surgeons

For its first initiative, the consortium agreed to focus on the pain care of the routine, non-complex (i.e., opioid-naïve) adult surgical patient. Over the course of several months, using Delphi methodology and culminating in the first live virtual Pain Summit involving all participating societies, this multiorganizational consensus process resulted in the establishment of 7 guiding principles for acute perioperative pain management.

Now published in Regional Anesthesia & Pain Medicine, these principles are intended to help healthcare systems and individual clinicians provide better care for patients having surgery. These principles include the need for preoperative evaluation of medical and psychological conditions and potential substance use disorders, a focus on multimodal analgesia including nonpharmacologic interventions, use of validated pain assessment tools to guide and adjust treatment, and the importance of individualized care and education, among others.

The final seven principles are:

  1. Clinicians should conduct a preoperative evaluation including assessment of medical and psychological conditions, concomitant medications, history of chronic pain, substance use disorder, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan.
  2. Clinicians should use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly.
  3. Clinicians should offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in adults.
  4. Clinicians should provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for managing postoperative pain, and document the plan and goals for postoperative pain management.
  5. Clinicians should provide education to all patients (adult) and primary caregivers on the pain treatment plan, including proper storage and disposal of opioids and tapering of analgesics after hospital discharge.
  6. Clinicians should adjust the pain management plan based on adequacy of pain relief and presence of adverse events.
  7. Clinicians should have access to consultation with a pain specialist for patients who have inadequately controlled postoperative pain or are at high risk of inadequately controlled postoperative pain at their facilities (e.g., long-term opioid therapy, history of substance use disorder).

The formation of this consortium is a critical first step to widespread quality improvement in perioperative pain management for surgical patients across the country. The fact that 14 professional healthcare organizations could agree on these 7 principles means that the bar for acute perioperative pain management has been reset.

The work product of this consortium can now form the basis of all future guidelines and influence the products of legislation and regulation that affect pain management for surgical patients. There is still so much work to do, however, and this consortium is already looking at how to tailor these principles to more complex surgical populations, better assess barriers to change implementation, and provide each organization’s members with the tools they need to improve acute perioperative pain management where they are.

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Anesthesiology, Healthcare, Pain Medicine

7 Guiding Principles for Acute Perioperative Pain Management

I had the privilege of co-chairing the 2021 Pain Summit hosted by American Society of Anesthesiologists (ASA). In the months preceding the summit, ASA physician volunteers and staff as well as representatives from 14 other surgical specialty and healthcare organizations worked towards achieving consensus on a common set of principles to guide physicians and other clinicians who manage acute perioperative pain.

These 7 proposed principles are:

  1. Conduct a preoperative evaluation including assessment of medical and psychological conditions, concomitant medications, history of chronic pain, substance abuse disorder, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan.
  2. Use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly.
  3. Offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in adults.
  4. Provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for managing postoperative pain, and document the plan and goals for postoperative pain management.
  5. Provide education to all patients (adult) and primary caregivers on the pain treatment plan, including proper storage and disposal of opioids and tapering of analgesics after hospital discharge.
  6. Adjust the pain management plan based on adequacy of pain relief and presence of adverse events.
  7. Have access to consultation with a pain specialist for patients who have inadequately controlled postoperative pain or at high risk of inadequately controlled postoperative pain at their facilities (e.g., long-term opioid therapy, history of substance use disorder).

This is the first project from this new collaborative, which focused on the adult surgical patient, and there are already plans for future projects. The participating organizations are:

  • American Academy of Orthopaedic Surgeons
  • American Academy of Otolaryngology-Head and Neck Surgery
  • American Association of Neurological Surgeons
  • American Association of Oral and Maxillofacial Surgeons
  • American College of Obstetricians and Gynecologists
  • American College of Surgeons
  • American Hospital Association
  • American Medical Association
  • American Society of Breast Surgeons
  • American Society of Plastic Surgeons
  • American Society of Regional Anesthesia and Pain Medicine
  • American Urological Association
  • Society of Thoracic Surgeons

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Anesthesiology, COVID-19, Healthcare, Pain Medicine, Patient Safety, Regional Anesthesiology

We Still Have an Opioid Epidemic

COVID-19 has changed every aspect of our personal and professional lives.

In the midst of this pandemic, we still have an opioid epidemic. It is not one thing unfortunately, and the Centers for Disease Control and Prevention (CDC) describe three distinct waves of opioid-related overdose deaths.

Centers for Disease Control and Prevention

Given the complexity of the opioid epidemic, we have to keep working within our spheres of influence. For those of us in anesthesiology, that means focusing on surgical patients: improving their outcomes and providing effective perioperative pain management along with opioid stewardship.

Dr. Chad Brummett and his colleagues at Michigan OPEN have been leading the way in procedure-specific opioid prescribing recommendations. Their process, which takes into account data from the Collaborative Quality Initiative (CQI), published studies, and expert input, specifically focuses on the perioperative care of patients who are not taking any opioids prior to surgery.

Continue reading We Still Have an Opioid Epidemic →

Through multimodal analgesia, we prevent and treat pain in a variety of ways without depending solely on opioids.

At our institution, we offer patients regional anesthesia and have been able to decrease the amount of opioid pills that patients are given when they leave the hospital by basing the prescription on how much they use the prior day. Patients participate in this process, and we give them clear instructions on how to safety taper their opioids at home.

As a representative of the American Society of Anesthesiologists (ASA), I have been able to collaborate with surgical societies such as the American Society of Breast Surgeons and the American Academy of Orthopaedic Surgeons to develop pain management recommendations and toolkits that emphasize multimodal analgesia, use of regional anesthesia techniques for targeted non-opioid pain management when it is available, and opioid safety in the hospital and at home.

ASA-AAOS Pain Alleviation Toolkit

I also represent ASA as a member of the National Academy of Medicine (NAM) Action Collaborative Countering the U.S. Opioid Epidemic. The first discussion paper from the NAM pain management workgroup was released on Aug 10: Best Practices, Research Gaps, and Future Priorities to Support Tapering Patients on Long-Term Opioid Therapy for Chronic Non-Cancer Pain in Outpatient Settings. This paper highlights best practices in opioid tapering and identifies evidence gaps to drive future research.

Despite the massive amount of resources, human effort, and time dedicated to the fight against COVID-19, we have still managed to make progress in decreasing opioid-related risk in the perioperative period. However, there is still a lot of work left to do, and our patients are depending on us.

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Anesthesiology, Healthcare, Leadership, News, Pain Medicine, Patient Safety, Regional Anesthesiology

My Trip to Washington: Speaking Out Against Drug Shortages

UPDATE: The MEDS Act was incorporated into the Coronavirus Aid, Relief, and Economic Security (CARES) Act and passed into law on March 27, 2020. I commented on the COVID-19 pandemic’s exacerbation of ongoing drug shortages in this interview with CBS news.

On November 5, 2019, I had the opportunity to participate in a Congressional briefing related to drug shortages at the Capitol in Washington, DC. Senator Susan Collins (R-ME) opened the session and co-sponsored the Mitigating Emergency Drug Shortages (MEDS) Act with Senator Tina Smith (D-MN). I was one of only two physicians on the panel and tried to represent the voice of clinicians involved in perioperative care and the patients we care for (video). Below are the notes from my presentation.

As a physician specializing in anesthesiology, this ongoing crisis of drug shortages in the United States is frankly terrifying.

Continue reading My Trip to Washington: Speaking Out Against Drug Shortages →

Anesthesiology is a unique specialty within medicine. Our patients are the most vulnerable in the hospital. Patients under general anesthesia cannot advocate for themselves and trust us with their lives.

We do not know what the next drug shortage will be or how long it will last. This week it is prefilled syringes of lidocaine, a life-saving emergency medication we give in case of a dangerous heart rhythm. Two weeks ago it was phenylephrine, a routine medication we use to increase blood pressure when it goes down after inducing anesthesia.

Last year, we had complete shortages of common injectable opioids and local anesthetics used for numbing injections. This directly affected surgical patients in terms of anesthesia and pain management. For 3 months in 2018, we did not have the local anesthetic indicated for spinal anesthesia. We know this is the safest anesthetic for patients having certain surgeries. During this shortage, we used an alternative anesthetic in order to continue providing spinal anesthesia, but our patients experienced more side effects. The reasons for this shortage were complex and involved a limited number of manufacturers and quality issues.

Thankfully, the shortage of spinal local anesthetic ended. We do not know when or if the rest of our current drug shortages will end. All we know for sure is that there will be another one.

The predictably unpredictable cycle of drug shortages puts physicians in an impossible position. Medicine is a calling, and we physicians have sworn an oath to support the well-being of our community and humanity in general.

Not having access to the right drugs at the right time for every patient and being forced to use less acceptable alternatives, if any exist at all, represents a form of moral injury. Moral injury “is being unable to provide high-quality care and healing in the context of health care” and is now recognized as a contributor to the epidemic of physician burnout.

Listen to my interview with Paul Costello on SoundCloud.

From left to right: Daniel Teich (Fairview Pharmacy Services), Dr. Peter Adamson (Children’s Hospital of Philadelphia), Senator Susan Collins, me, and Brian Marden (MaineHealth Pharmacy)

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Anesthesiology, CME, Healthcare, Medical Education, Pain Medicine, Patient Safety, Regional Anesthesiology, Research

My Top Ten Articles for #RAUK20

I have the honor of being the next Bruce Scott Lecturer for the 2020 Regional Anaesthesia United Kingdom (RA-UK) meeting in Sheffield on May 18 and 19, 2020.

As part of the preparation for what will be a fantastic conference filled with the latest education in regional anesthesia, point-of-care ultrasound, acute pain management, and social media for medical education, Dr. Amit Pawa has started a thread on Twitter featuring my “Top Ten” published articles.

I hope to see you at #RAUK20! You can access the thread and check out the list of articles by clicking the tweet below:

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Healthcare, Medical Education, Pain Medicine, Regional Anesthesiology, Social Media

Regional Anesthesia Education and Social Media

At the 2018 annual meeting of the European Society of Regional Anaesthesia and Pain Therapy (ESRA), I was invited to give a talk on regional anesthesia education and social media.  In case you missed it, I have posted my slides on SlideShare.

After my session, I was asked by ESRA to highlight some of the key points of my lecture:

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Anesthesiology, CME, Medical Education, Pain Medicine, Patient Safety

My Reasons to Visit San Francisco for #ANES18

This year’s American Society of Anesthesiologists meeting (#ANES18) happens to be in my “neck of the woods”—one of the greatest cities in the world—San Francisco, California. Here are a few things you may or may not have known about San Francisco.

San Francisco is the biggest little city. At just under 47 square miles and with more than 800,000 inhabitants, San Francisco is second only to New York City in terms of population density. Despite its relatively small size, “the City” (as we suburbanites refer to it) consists of many small neighborhoods, each with its own charm and character: Union Square, the Financial District, Pacific Heights, the Marina, Haight-Ashbury, Chinatown, Little Italy, Nob Hill, Russian Hill, SoMa (South of Market), the Fillmore, Japantown, Mission District, Noe Valley, Twin Peaks, Castro, Sunset, Tenderloin, and others. This is probably why die-hard New Yorkers love it so much.

In the summer especially, San Francisco weather is somewhat unpredictable even when going from one side of the city to the other (part of the unique experience of visiting the city). “The coldest winter I ever spent was a summer in San Francisco,” a quote often mistakenly attributed to Mark Twain (no one really knows who actually said it), is nevertheless often true. Here in the San Francisco Bay Area, our local meteorologists provide daily forecasts for each of the region’s microclimates. The western side of the City along California’s coast is regularly plagued with fog while the eastern side of the City tends to be sunny most days of the year. It’s always a good idea to check the microclimate forecast before heading over to see the Golden Gate Bridge just in case it happens to be shrouded in fog. Average July temperatures in the City range in the 50s-60s Fahrenheit (no different than average November temperatures), so summer tourists often contribute to the local economy by buying “SF” logo sweatshirts for their walk across the City’s most famous bridge. Fortunately, #ANES18 is in the fall, and the weather near Moscone Center and the popular shopping area Union Square tends to stay reliably nice most of the year.

San Francisco is very family-friendly. If you’re debating whether or not to make a family trip out of #ANES18, my advice is to do it. Right around the convention center there are a number of attractions and events worth checking out. I highly recommend visiting the farmers market at the Ferry Building. While there, you can also take a ferry ride to a number of other destinations in the Bay Area (try Sausalito, a short trip that takes you past Alcatraz). For kids, there are parks within walking distance as well as the Children’s Creativity Museum, the San Francisco Railway Museum, Exploratorium, and the cable car turnabout at Powell and Market Street. Trips to Fisherman’s Wharf, Ghiradelli Square, or the aquarium are a short taxi or cable car ride away. In addition, runners will love running up and down the Embarcadero which gives you a view of the Bay Bridge and takes you past the City’s many piers. Shoppers will be in heaven, and foodies will have to make the impossible decision of choosing where to eat for every meal.

But don’t take my word for it—come to #ANES18 and see for yourself!

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Anesthesiology, Healthcare, Outcomes Research, Pain Medicine, Patient Safety, Regional Anesthesiology, Research

Why We Should Worry about Drug Shortages in Regional Anesthesia

The crisis of prescription opioid overuse and abuse has affected countries around the world, and anesthesiologists are well-positioned to make positive changes (1).  Even minor outpatient surgical procedures, and their associated anesthesia and analgesia techniques, can lead to long-term opioid use (2,3).  Patients who present for surgery with an active opioid prescription are very likely to still be on opioids after a year (4).

Anesthesiologists have been working to set up regional anesthesiology and acute pain medicine programs with careful coordination of inpatient and outpatient pain management to improve patient outcomes.  Regional anesthesia, especially with continuous peripheral nerve block (CPNB) techniques, has been shown repeatedly to reduce patients’ need for opioid analgesia (5).

Today, the crisis of drug shortages threatens to reverse many advances in acute pain management.

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Today, the crisis of drug shortages threatens to reverse the many advances in perioperative pain control that have been achieved.  Local anesthetics or “numbing medications” represent a class of drugs that is our strongest weapon against opioids.  These drugs (e.g., bupivacaine, lidocaine, ropivacaine) are currently in shortage.  Targeted injections of local anesthetic in the form of regional anesthesia eliminate sensation at the site of surgery and can obviate the need for injectable opioids (e.g., fentanyl, hydromorphone, morphine) which also happen to be in short supply.  Local anesthetics are also the critical ingredient in providing epidural pain relief and spinal anesthesia for childbirth.  Without them, new moms will miss the first moments of their babies’ lives.

The following are potential ramifications of the current drug shortages affecting anesthesia and pain management on patient care:

Decreased Quality of Acute Pain Management

Regional anesthesia techniques, which include spinal, epidural, and peripheral nerve blocks, offer patients many potential advantages in the perioperative and peripartum period.  Human studies have demonstrated the following benefits: decreased pain, nausea and vomiting, and time spent in the recovery room (6,7).  Long-acting local anesthetics (e.g., bupivacaine, levobupivacaine, and ropivacaine) generally provide analgesia of similar duration for 24 hours or less (8-11).  These clinical effects of nerve blocks typically last long enough for patients to meet discharge eligibility from recovery and avoid unnecessary hospitalization for pain control (12).  CPNB techniques (also known as perineural catheters) permit delivery of local anesthetic solutions to the site of a peripheral nerve on an ongoing basis (13).  Portable infusion devices can deliver a solution of plain local anesthetic for days after surgery, often with the ability to titrate the dose up and down or even stop the infusion temporarily when patients feel too numb (14,15).  In a meta-analysis comparing CPNB to single-injection peripheral nerve blocks in humans, CPNB results in lower patient-reported worst pain scores and pain scores at rest on postoperative day (POD) 0, 1, and 2 (16).  Patients who receive CPNB also experience less nausea, consume less opioids, sleep better, and are more satisfied with pain management (16).  By using local anesthetic medication to interrupt nerve transmission along peripheral nerves, patients continue to experience decreased sensation as long as the infusion is running.  A shortage of local anesthetic medications makes it impossible for anesthesiologists to provide this potent form of opioid-sparing pain control for all surgical patients.  This also means that local anesthetics cannot be administered by surgeons as wound infiltration to help patients with incisional pain, and epidural analgesia for laboring women may not be universally available.

Increased Incidence of Postoperative Complications

Based on the study by Memtsoudis and colleagues, overall 30-day mortality for total knee arthroplasty patients is lower for patients who receive regional anesthesia, either neuraxial and combined neuraxial-general anesthesia, compared to general anesthesia alone (17).  In most categories, the rates of occurrence of in-hospital complications (e.g. all-cause infections, pulmonary, cardiovascular, acute renal failure) are also lower for the neuraxial and combined neuraxial-general anesthesia groups vs. the general anesthesia only group, and transfusion requirements are lowest for neuraxial anesthesia patients compared to all other groups (17).  The inability to offer regional anesthesia (e.g., spinal or epidural) to all patients due to lack of local anesthetics therefore represents a threat to patient safety.

Increased Risk of Persistent Postsurgical Pain

Chronic pain may develop after many common operations including breast surgery, cesarean delivery, hernia repair, thoracic surgery, and amputation and is associated with severe acute pain in the postoperative period (18).  A Cochrane systematic review and meta-analysis reviewed published studies on this subject, and the results favor epidural analgesia for prevention of persistent postsurgical pain (PPSP) after thoracotomy and favor paravertebral block for prevention of PPSP after breast cancer surgery at 6 months (19).  Only regional blockade with local anesthetics can block patients’ sensation during and after surgery.  Without local anesthetics for nerve blocks, spinals, and epidurals, patients will experience greater than expected acute pain, require additional opioid treatment, and potentially be at higher risk of developing chronic pain.

Increased Health Care Costs

Approximately 31% of costs related to inpatient perioperative care is attributable to the ward admission (20).  Anesthesiologists as perioperative physicians have an opportunity to influence the cost of surgical care by decreasing hospital length of stay through effective pain management and by developing coordinated multi-disciplinary clinical pathways (21,22).  Regional anesthesia and analgesia can improve outcomes through integration into clinical pathways that involve a multipronged approach to streamlining surgical care (23,24).  Inadequate pain control can delay rehabilitation, prolong hospital admissions, increase the rate of readmissions (25), and increase the costs of hospitalization for surgical patients.

In summary, regional anesthesia and analgesia has been shown in multiple studies to improve outcomes for obstetric and surgical patients.  The current shortage of local anesthetics and other analgesic medications negatively affects quality of care and pain management and is a threat to patient safety.

References

  1. Alam A, Juurlink DN. The prescription opioid epidemic: an overview for anesthesiologists. Can J Anaesth 2016;63:61-8.
  2. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period. JAMA internal medicine 2016;176:1286-93.
  3. Rozet I, Nishio I, Robbertze R, Rotter D, Chansky H, Hernandez AV. Prolonged opioid use after knee arthroscopy in military veterans. Anesth Analg 2014;119:454-9.
  4. Mudumbai SC, Oliva EM, Lewis ET, Trafton J, Posner D, Mariano ER, Stafford RS, Wagner T, Clark JD. Time-to-Cessation of Postoperative Opioids: A Population-Level Analysis of the Veterans Affairs Health Care System. Pain Med 2016;17:1732-43.
  5. Richman JM, Liu SS, Courpas G, Wong R, Rowlingson AJ, McGready J, Cohen SR, Wu CL. Does continuous peripheral nerve block provide superior pain control to opioids? A meta-analysis. Anesth Analg 2006;102:248-57.
  6. Liu SS, Strodtbeck WM, Richman JM, Wu CL. A comparison of regional versus general anesthesia for ambulatory anesthesia: a meta-analysis of randomized controlled trials. Anesth Analg 2005;101:1634-42.
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