Episode 6: Opioid-Free Surgery: One Patient’s Story

Opioid Conversations with Surgeons

Wendy Nickel:

Thank you both for being here today to share a little bit about your surgery story. My name is Wendy Nickel. I'm the president of the Healthcare Improvement Foundation and I have a deep background in shared decision making between patients and clinicians. I'm really excited to speak with both of you and better understand what led you to the idea of opioid-free surgery and that's what we're going to be talking about today. I would love it if you would introduce yourselves. Starting with Dr. Bar, if you could share a little bit about you and your background, and then we'll go to Donielle.

Dr. Allen Bar:

I'm Allen Bar. I was a surgeon at Pennsylvania Hospital. Retired about a year ago. I've been in practice for 47 years doing general surgery, primarily breast, GI surgery, and hernias.

Starting in 2015—in answer to your question about how I got interested—three of us got involved with enhanced recovery. I was the surgeon. The other two were quality nurses who were involved in quality and data. And we realized that there were some issues at our hospital as far as data was concerned. I had heard a lecture on enhanced recovery and felt that this was something that we should do. And a big part of enhanced recovery is non-opioid analgesia and anesthesia. And that when I got really involved.

At a personal note, I've known for 20 or 25 years that I cannot come near an opioid, even something as little as low modal, without getting violently ill. And making it personal, I've tried to figure out if I needed any major surgery, what are the alternatives? Well, enhanced recovery gave us that and in my practice the last five, six years, even more than that I have pretty much eliminated opioids from my postoperative care.

Wendy Nickel:

Great. Thank you, Dr. Bar.

Donielle, would you provide an introduction please?

Donielle Calabrese:

Hi, good afternoon. I'm Donielle Calabrese and I was a patient of Dr. Bar's in 2018. I had a hernia repair and I knew of Dr. Bar and sought him out to do my surgery—one of the reasons being he's an excellent surgeon, but also I knew that he did not prescribe narcotics and in the past I did not do well with opioids. I tend not to take them anyway. So sometimes I'm prescribed yet I don't even get them filled.

So my professional background is I am a registered nurse in the University of Pennsylvania health system. And I've been a nurse for 29 years. And right now in the last 10 years I've worked in the recovery room, so I recover patients from surgery. Prior to that, I worked in an ED for 10 years. Before that it was in surgical units. I have a lot of background with pain management.

Wendy Nickel:

Great. Thank you, Donielle. So Dr. Bar, turning it back over to you, can you tell us a little bit about the procedure that Donielle required?

Dr. Allen Bar:

Well, I do open hernia repairs. And as you may or may not know, in the past we used to give 40 Percocets for this. Realizing that this was not the way I wanted to go. As I say, it's an open hernia repair. It is "theoretically" very painful... I operate on Tuesdays and I will say to the patients, "You will not like me until Thursday afternoon."

And I hate to use the word pain. Pain implies something bad, and I much prefer to use discomfort. So I talk to the patients about surgery does hurt and they'll be uncomfortable. And we give them pre-op Tylenol. Intraoperative we give them Toradol. And I use Marcaine and ice on their wound, all of which have shown to decrease "pain" or discomfort. Then they go on every three hours Tylenol and ibuprofen alternating. I have had over a hundred patients in this and I think maybe two or three have called and asked for any kind of narcotics and I usually give about two or three pain pills. So it's been very successful. Most of my patients I do talk to beforehand, like Donielle, as soon as I say I don't use narcotics, they smile and say, "I don't want them."

Wendy Nickel:

Thank you. Donielle, can you talk a little bit about how you did after surgery with the opioid free techniques. How did you feel in the days post surgery and throughout your recovery?

Donielle Calabrese:

I did very well. I will tell you Dr. Bar did call me the next day. That evening of the surgery. I did take Motrin and Tylenol. The next day I remember talking to Dr. Bar and I said to him, "I haven't taken anything." And he's like, "Well, maybe you should take a little bit of Motrin at least or something so you don't have discomfort and that you can move around better." But I honestly felt like I didn't need anything. And I only took it because he told me to take it. I probably wouldn't have taken the Tylenol and Motrin either.

Dr. Allen Bar:

If I may also, three years ago I had my hernia fixed. And again, I did not take any opioids and it was done on a Thursday and by Friday I wasn't taking anything and I had no pain. And as a matter of fact, I went to the gym on Monday. So, as I say, it's a mindset and it can happen.

Wendy Nickel:

So Dr. Bar, thinking about before and after, so before when you used to use opioids versus the opioid-free surgery approach that you're using now, what would you say is the difference in recovery?

Dr. Allen Bar:

It's much quicker without opioids. There's just no question about it. That's across the board. And I will get into more detail about all the side effects of opioids, but they're significant. They cover about 70% and they all set you back. It's totally a different mindset and a different recovery. The patients get better much quicker.

Wendy Nickel:

Donielle, how would you say your recovery went? You talked about the days immediately post-surgery and your pain, but how soon did you feel like you were back to yourself and able to go back to work and daily activities?

Donielle Calabrese:

Within three days I was back to work. Physically, I didn't feel any... I had maybe a little discomfort here and there, feel a little pull, a little burn because it's healing. But other than that I did very well. I did use ice. I do think it's your perception of pain and I also think it's having those open conversations with your surgeon or your provider, any provider.

I think you need to know what the patient's expectations are, what your physician expects. I think we need to be honest with the patients: you are going to feel some discomfort. You're not going to walk out and think, "Oh, I'm going to have a regular day. I'm just going to feel great. I'm going to be able to do all my normal activities." That's not possible and I think as providers and even as patients we need to know that we are going to feel some discomfort. You're not going to have surgery and not feel anything, but we need to know that it's okay what you're feeling and that in a couple of days you will be back to yourself.

Wendy Nickel:

Great. Thank you. And Donielle, given that you're a recovery room nurse, how has this changed your approach to caring for patients? Has it changed how you take care of patients or how you communicate with them about pain?

Donielle Calabrese:

I would say yes, it does. Not all, but many patients are educated also and they are very aware of the epidemic that we have going on with opioids. Some of them don't even want to take any pain medications and it depends on the patient themselves and what their expectations are. I'm not going to say I don't give pain medications because I still do, but I try to not give as much or really see where they are and use other techniques. Changing body position, using ice when appropriate. We've even tried imagery. There's music therapy. There are things that we can use other than medications.

Wendy Nickel:

Dr. Bar, I'm interested in hearing about your colleagues' reaction to opioid-free surgery. Have you had colleagues that question that approach? I'm just curious how folks are reacting in the healthcare field.

Dr. Allen Bar:

Where do I start? We could start early on. We've been married to opioids for a long time. In the nineties no patient should have any pain. And I think that marriage is very difficult to leave and break up. I'm a little disappointed because I've been listening to this podcast of surgeons that I have tremendous respect for. "You'll never eliminate opioids." Well, with that attitude, you're not going to eliminate opioids. Once you put it on the order sheet, you will never get rid of it. And there are ways to do this.

So it's very hard for me to change a culture and something that's been living with. It's easier to use opioids. We could talk about opioids. Everybody thinks that they're the best for pain. And I can get into studies that disprove that. I don't know if people are aware of it, but there was two studies in 2019 and 2017 in JAMA which blinded patients who came into the emergency room with acute pain, joint pain, back pain, knee pain.

All of them took Tylenol and three of them had narcotics, codeine, oxycodone, or hydromorphone. And the other had 400 milligrams of ibuprofen with that. They were blinded. Each patient put down their pain level when they came in and two hours later they put down their pain level when the medications were at their peak. And guess what the results were? There was no difference. As a matter of fact, if you looked very carefully and not statistically, the Tylenol and ibuprofen were just slightly below Percocet. And Percocet is the most potent of them. Maybe we don't need to use opioids.

Wendy Nickel:

Donielle, how would you recommend opioid-free surgery to friends and family? What would you say to them about your experience and the idea of going opioid-free?

Donielle Calabrese:

Well, I can tell you I just had an experience back in June. My daughter had surgery. She had ENT surgery. So she had a deviated septum and some other nasal surgery done. And it's funny. She's only 20 years old and yet she herself did not want to take opioids.

She really didn't have much pain and it's a pretty painful procedure, but she really didn't have much pain. And she only took Tylenol and she did very well and I feel she recovered much quicker than someone that would take opioids because you're just more alert and you're more mobile. And I think you care for yourself better when you're more alert than if you're taking opioids. There's so many side effects. Besides dizziness, sleepy, constipation, there's so many issues that go along with opioids. So, from my own experience, I've had my own child who I didn't give anything to except Tylenol. And that was recently.

Wendy Nickel:

Yeah. Interesting. Dr. Bar, can you talk a little bit about how you became interested in opioid-free surgery? How did you go about developing a technique that would help to really minimize pain without opioids?

Dr. Allen Bar:

First of all, the biggest thing is engaging the patient. It takes about five more minutes. You really need to spend time. And as surgeons…

In the operating room I would talk to anesthesia. There is a knee jerk for fentanyl and I had fights. "I don't want my patients to get fentanyl." "Oh, but it just doesn't hurt." Well, most studies show that it does hurt them. So I do use Toradol, which is a nonsteroidal. I always, unless it's a nothing surgery, will inject Marcaine so that at least for four to six hours they're not uncomfortable in that respect. And there are studies that show that icing—controlled studies—icing thoracotomies, and patients who had the ice did better. So there are lots of little things. It's what you do in the office that is as important as anything else.

And then tell the patients, exactly like Donielle said, what to expect. "You're going to be uncomfortable." We only need you to do four things, regardless of what surgery. You need to sleep, eat, get out of bed, and walk. And patients are very happy to be uncomfortable if they can do that because they're going to get better much quicker. And that's the number one priority for any patient. No matter how you get sick, the first thing you think about is when am I going to get better? And then, what can I do to get better quicker? And I'll tolerate some pain and I'll tolerate not sleeping. I'll tolerate looking terrible if I can get better quicker.

Wendy Nickel:

Donielle, back to you, I had a question about the communication that you had with Dr. Bar. I'm sure that there was some anxiety about having the surgery and not utilizing opioids. What did Dr. Bar tell you that helped you to feel trust in his approach and feel comfortable with how to have your surgery without opioids?

Donielle Calabrese:

Well, I think he was honest with me. He didn't dance around the subject. He didn't say that I wouldn't be uncomfortable. He didn't make me think that it was going to be discomfort free, pain free. He told me that basically to have confidence that the Tylenol and Motrin would work and ice and that I would feel pretty good.

And I feel like if you say to somebody, "You're going to have discomfort. You're going to have pain," I think our idea is that it's probably worse than it really is. And so it's the opposite effect; so, if I said to you, "You're going to wake up and you're going to have surgery and we're going to take your pain away completely and you're going to have no pain," and if I woke up and had even the smallest amount of pain, it would feel excruciating because that's not what I expected. But if I expect to have some discomfort, if I expect to have... I use the word pain. Pain. Then I don't know. I feel like my perception of waking up: "Oh, this isn't so bad."

Wendy Nickel:

Dr. Bar, just a question about how somebody would identify a surgeon who doesn't use opioids. Is there some list? Or how would you find out that a surgeon doesn't use opioids for their surgery?

Dr. Allen Bar:

You can't. Right now you can't and maybe we should advertise on our website saying, opioid-free surgery. It might sell, but I think you need to market it. But the answer to your question is: right now, you can't tell unless the doctor tells you in the office.

Wendy Nickel:

So how would you recommend a patient approach that with their surgeon? If they don't know that their surgeon is pro-opioid-free surgery, how would you recommend a patient perhaps approach that?

Dr. Allen Bar:

You just have to approach it. You just have to be very point blank and you have to advocate for yourself. "I would prefer not to use opioids."

Wendy Nickel:

Donielle, this is the final question, but what's the most important message you'd like to share about opioid-free surgery to patients or to your colleagues who work in the healthcare field?

Donielle Calabrese:

For patients, I think it's almost like you need to try it to know. So I always encourage the use of other sources other than opioids to begin with. When I give instructions to my patients, even if they are prescribed opioids, I tend to tell them to start out with Tylenol or Motrin. And then if you continue to have pain even after you take those medications, then you can add on an opioid.

I find that patients do well with that because I feel like they have control. So they know that they have the opioid if they should need it, but they use the other medications first as a first line. And then it's not that fear that, "I'm going to go home and have pain and I'm not going to know what to do." We've given them other options and put them in control of their own surgery, their own pain, and their own recovery.

Wendy Nickel:

And Dr. Bar, same question. What's the most important message you'd like to convey about opioid-free surgery?

Dr. Allen Bar:

We need to get there. And I'd like to end with a challenge to my co-surgeons and co-workers in the field. We need to look at our goal as opioid-free now.

If I may, I'll tell you a story. It was a plastic surgeon who does difficult breast reconstruction, abdominal transplants. They're long operations. When I first talked to him about it was 2015. His patients were in the ICU with PCA pumps for two or three days, Foley catheters, not in bed.

But when he looked down at his reconstructive surgery, the addiction rate was almost 20%. It was 19%. And he said to himself, "I'm doing nothing for the patient other than making their life more pleasant. I don't do anything for life. I've got to change." And what he did... He changed his technique a little bit. He premedicated them. They get chest blocks. They get abdominal wall blocks and they get no opioids. They get IV Tylenol and the other things that anesthesia can use that are not opioid.

The only time his patients get opioids, the nurses have to call him at home. There's no order on the chart. No resident, no fellow can order it. They have to call him at home to have permission for his patients to have opioids. And that's the key. Opioids are not written for any of the plastic surgery patients. They have to come from direct order from him at home. And he said if the patient's uncomfortable at three in the morning, you can call him. Once it’s on the chart, they’re going to get it.

So what happened was he's done over a hundred of these. Instead of patients going home on five to seven or eight days, he's sent patients home on even day one, day two. Their average length of stay is two to three days. 75% of his patients take no opioids. That's for major, major league surgery.

C-sections if you use opioids has a 5% addiction rate. Just think of the numbers and think of what addiction does. So we really need to look at what we're doing to our patients. And I think that's the biggest selling point. And it doesn't take more than one day of opioids to have this addiction. And then here's the other statistic: 80% of heroin addicts now started with prescription opioids. We can be preventive doctors. If we don't give opioids, they're not going to be in that 80%. So that's my message to my colleagues.

Wendy Nickel:

Wow. Pretty dramatic statistics. So I just want to thank you both so much for speaking with me today. I think this conversation will go a long way to really change the dialogue about surgical opioid stewardship. Really appreciate your participation. Thank you.

Donielle Calabrese:

Thank you.

Dr. Allen Bar:

Glad we could get our message across. Thank you very much for having us.