Proactive Pain Management

Patient before surgery
Samantha Muise receives a nerve block before her shoulder surgery. As part of the study patients are given a pre-emptive dose of an opioid pain killer to take at home when the nerve block wears off.

NSHA anesthesiologists and orthopedic surgeons want to ease the post-operative discomfort of a particularly painful procedure, the arthroscopic rotator cuff repair.

“This is a common shoulder surgery, which is very painful for many people,” notes Dr. Vishal Uppal, the anesthesiologist who is leading the study. “We are testing a new protocol to see if giving patients a single pre-emptive dose of an opioid painkiller to take after they get home will prevent the pain from getting out of control.”

As Dr. Uppal explains, once pain really kicks in, it is difficult to bring it under control and patients may require more painkillers. It is far safer and more effective to prevent the pain from getting that bad in the first place.

Minimizing pain during and immediately after surgery is the crucial first step, of course. In addition to general anesthesia, patients undergoing arthroscopic shoulder surgery also receive a local nerve block that freezes the shoulder for six to eight hours.

“The local nerve block reduces the amount of anesthetic required during the surgery, which is very beneficial,” Dr. Uppal says. “It reduces anesthesia side effects such as, nausea, vomiting, itching and breathing issues.”

The lack of potential anesthesia complications also makes it possible for patients to go home within a few hours of the outpatient surgery. The problem is, by this time, the nerve block is wearing off.

“Now the patient may be in a lot of pain and it can be very difficult to get ahead of that pain and bring it under control,” says Dr. Uppal, noting that these patients would typically have only over-the-counter pain medications like acetaminophen, ibuprofen and naproxen at their disposal. As a result, patients may end up in their doctor’s office or an emergency room, seeking a prescription for relief. “But now the pain may be more intense and they may need a fair bit of opioid painkiller to bring it under control.”

Dr. Uppal, Dr. Janny Ke (anesthesia resident) and his collaborators, including Dr. Andrew Trenholm in the Division of Orthopedic Surgery, have an NSHA Research Fund grant to test the pre-emptive dose of opioid— compared to a placebo—in a two-year trial involving 70 patients undergoing arthroscopic shoulder surgery.

“They will fill in a pain diary and we will call them to check on how they are doing with their pain,” Dr. Uppal says. “If it proves effective, we will have paved the way to a safe and effective strategy for safely heading off pain at the pass.”