America has an opioid problem. No matter which metric you look at — overdose rates, addiction rates — the problem seems to be getting worse. Since 1999, over 760,000 Americans have died from a drug overdose. In 2018, two out of three of those deaths involved opioids, making opioids a leading cause of death in the U.S.
While there are myriad reasons people become addicted to opioids, one is opioid use during and after surgery. One in five patients is still using opioids three months after surgery, and 3%-4% become chronic users. But what if doctors didn’t have to prescribe opioids after surgery to manage pain? One surgery team at Northwell Health, led by Dominick Gadaleta, MD, chair of surgery at South Shore University Hospital and David Pechman, MD, bariatric surgeon at South Shore University Hospital, decided to find out.
“Several years ago, I was asked as part of a team to help shorten length of stay and to see what the barriers were,” Dr. Gadaleta recalled in a recent episode of Northwell’s podcast, 20-Minute Health Talk. “What we all quickly learned was that the things that we were doing to the patient were part of the barriers to recovery. And as it turns out, one of the most important things besides innovative surgical techniques is the elimination of opioids. This led to a concept of enhanced recovery, which was going on in Europe. We quickly adapted it to our program at NSUH.”
Pain management
How Innovative Pain Management Techniques Are Reducing Opioid Use in Northwell Hospitals
“Even if we can get the number of opioids prescribed from 30 to five, I think we’re doing good work,” said Dr. Gadaleta...“I want to see the day where it’s zero across the board.”
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Using an innovative pain management technique called nerve blocks, Drs. Gadaleta and Pechman have turned the status quo of bariatric surgery on its head. No longer are patients requiring long recoveries in hospital or being prescribed 15-30 opioids to manage pain. Now, patients recover quickly and only need traditional acetaminophen (Tylenol) to mitigate the painful side effects of surgery. Gone are the troubling side effects of opioids and the risk of addiction. It’s a transition that will most certainly save lives.
“What we saw when we ceased prescribing opioids to manage postoperative pain,” said Dr. Gadaleta, “was shorter length of stay, quicker recovery and better patient satisfaction.”
Though Northwell’s deployment of nerve blocks is part of a new and growing movement to reduce opioid use in ORs, nerve blocks themselves aren’t new. Most people have heard of an epidural, a type of neuraxial nerve block commonly used during childbirth. Along with traditional anesthesia, nerve blocks have been used in various capacities since 1885 when American surgical pioneer William Stewart Halsted invented them by injecting cocaine into the nerve trunk.
Nerve blocks act like a local anesthetic, numbing the nerves at a specific site for a specific amount of time. For example, using a nerve block at the site of a surgical incision prevents pain in the immediate aftermath of a procedure. Because pain doesn’t last forever ― it lessens every hour after surgery ― nerve blocks give patients a head start on recovery. The result is wonderfully effective: by preventing pain at the nerve site, a patient requires less pain management. As the nerve block gradually wears off, the pain threshold is greatly reduced from its apex. Instead of requiring Percocet or other opioids to manage the pain, a patient can now recover with over-the-counter pain medications such as acetaminophen or ibuprofen, completely eliminating the need for opioids.
Dr. Pechman was quick to point out that ditching opioids in the OR doesn’t mean patients are left to white-knuckle through their pain post-op. “We’re not withholding medication that the patients need,” said Dr. Pechman on the same 20-Minute Health Talk episode. “We do such a good job of multimodal pain therapy that the patients do not need those medications. And then if we can avoid the downstream effects of slower bowel motility, some patients will experience severe nausea or itchiness. Little things like that can become big things, then cause other issues. So if we can really eliminate all those downstream problems and let patients spend less time in the hospital and feel better, it’s really a win-win.”
At South Shore University Hospital, the transition away from opioids is spreading from bariatric surgeries to C-sections to ultrasound-guided usage in emergency departments. Like many successful innovations, it began with a change in perspective. Opioids treated a symptom; nerve blocks address the cause.
“Understanding basic anatomy and where the pain comes from is really the first key,” said Dr. Gadaleta of the shift. “If we can block pain and we do this with our anesthesia colleagues at its source at the nerve level, the patient does not experience pain. But the other thing is to have your colleagues, nursing staff and the entire team including the patient understand what pain really is. And it turns out we were treating other conditions with pain medication and oftentimes the opioids were making the conditions we were trying to treat worse.”
Dr. Gadaleta describes a common scenario in which a patient experienced bloating caused by the body’s natural stress response to surgery. Opioids were typically prescribed to address the pain caused by the bloating, but instead of helping, opioids increased the patient’s suffering.
Using nerve blocks in addition to preemptive medications goes a long way toward eliminating the pain before it starts by addressing it at its root cause.
The transition away from opioids at South Shore University Hospital has been swift and effective. After the program’s implementation in the bariatric program less than three years ago, the number of opioids used postoperatively fell to nearly zero within a couple of months. Now Dr. Pechman describes the presence of opioids as “virtually absent.”
From a patient perspective, the fact that the opioid epidemic has touched lives across all sectors of American life has made this transition to alternative pain management most welcome.
“Patients are really happy to hear that they will not need opiates in our program,” said Dr. Pechman. This is great news for Northwell patients, but Dr. Gadaleta isn’t satisfied.
To scale the program at a national level will require a multifaceted approach that includes awareness campaigns for patients and education at all levels of nursing and medical schools, as well as the expansion of pilot programs across the nation’s health care systems.
Yet Dr. Gadaleta is quick to point out that even the smallest reduction in the use of opioids has positive implications. For example, patients with chronic pain may come to the hospital using opioids.
Using nerve blocks during surgery may not eliminate their opioid use, but leaving the hospital without increasing usage is still a win. “Even if we can get the number of opioids prescribed from 30 to five, I think we’re doing good work,” said Dr. Gadaleta. “We can’t discourage people that need that crutch, but I want to see the day where it’s zero across the board.”
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Doctors are careful to send patients home with no more than a three-day supply of medication, usually over-the-counter pain medications like acetaminophen or ibuprofen, completely eliminating the need for opioids.
This necessary change has been made possible, in large part, to the advent of nerve blocks. The numbing effect, while a minor inconvenience, gives the body a 24-to-36-hour head start on the healing process. Considering that 3–4% of those who use opioid pain killers become addicted, the rise of nerve blocks will most certainly save lives.
ED staff at Staten Island University Hospital are trained to administer nerve blocks.
Northwell’s Staten Island University Hospital begins using nerve blocks for hip fractures in its Emergency Department (ED).
The blocks are administered with the guidance of ultrasound, greatly lessening the ED’s dependence on opioids and potentially ending their use altogether in the future.
Health systems around the country begin looking for alternatives to opioids.
Northwell Health, led by senior vice president for Northwell's anesthesia line, Joseph Marino, MD, introduces the use of nerve blocks in emergency care with the goal of taking it system-wide; Dominick Gadaleta, MD, David Pechman, MD and Andrew Bates, MD at Northwell’s South Shore University use nerve blocks during bariatric surgery. Northwell surgeons see massive benefits for patients, with quicker recovery, less pain and less exposure to opioids. Patients also avoid the physical side effects of opioid-based anesthesia, such as nausea and breathing issues.
Opioid addiction skyrockets in the U.S. due to overprescribing and overreliance on medical pain killers
Patients coming in for a procedure such as knee surgery go home with a three-month supply of oxycodone — 180 pills — despite only needing enough for three days. Huge vials of narcotics fill medicine cabinets across the U.S. Overdose deaths involving prescription opioids jump from 3,442 in 1999 to 17,029 in 2017. Overall, opioid-involved overdose deaths more than double in seven years: from 21,088 in 2010 to 47,600 in 2017. (Source: https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates)
FDA Amendments Act:
FDA Amendments Act granted FDA authority to require specified safety measures known as Risk Evaluation and Mitigation Strategies for certain drugs, but the FDA won’t act decisively on opioids for pain management until 2013.
As overdose deaths begin to skyrocket, FDA sends a warning letter to OxyContin manufacturer for misleading advertising.
Pain is labeled the 5th vital sign
Pain experts lobby to include pain alongside body temper ature, pulse rate, respiration rate and blood pressure as a vital sign that doctors must monitor and manage. This had the unintended consequence of striving for a goal of zero post-surgical pain.
Diagnostic ultrasound is used to administer nerve blocks more effectively.
+
2000s
2000s
+
2001
2001
2001
+
2003
2003
2003
+
2007
2007
2007
+
2000–2018
2000–2018
2000–2018
+
2020s
2020s
2020s
+
2021
2021
2021
+
September 2022
September 2022
September 2022
+
2022 and beyond
2022 and beyond
2022 and beyond
New painkillers marketed as “non-addictive” come to market with approval from the Food and Drug Administration (FDA):
Vicodin in 1984, OxyContin in 1995, Actiq (fentanyl) in 1998, and Percocet in 1999.
Nerve blocks enter common treatment:
Neuraxial nerve blocks like epidurals become commonplace during childbirth and in surgeries when a patient is deemed a poor candidate for traditional anesthesia.
Mayo Clinic surgeons use regional nerve blocks:
Mayo Clinic further develops peripheral and neuraxial nerve blocks (like epidurals), which block pain to a limb or groin, allowing physicians to ease pain during labor and surgeries.
U.S. bans opium:
In response to alarming rates of heroin addiction, the U.S. enacts the Smoking Opium Exclusion Act, effectively banning opium dens.
August Gustav Bier develops regional anesthesia:
The German surgeon finds a way to achieve intravenous regional anesthesia, allowing a patient to be awake during surgery without feeling pain from the site of the surgery.
William Steward Halsted tries nerve blocks for anesthesia:
An American surgical pioneer, Halsted invents nerve blocks by injecting cocaine into the nerve trunk.
A chemist stumbles upon heroin:
Attempting to create a less addictive form of morphine, English chemist C.R. Wright makes heroin by boiling morphine on a stove. Bayer later commercializes heroin for medical use at the turn of the century.
Scientists in Germany and UK invent syringes:
The first reliable syringes are developed. Injected morphine becomes the standard method of reducing pain during and after surgery.
+
1853
1853
1853
+
1874
1874
1874
+
1885
1885
1885
+
1908
1908
1908
+
1909
1909
1909
+
1925–1940
1925–1940
1925–1940
+
1980s
1980s
1980s
+
1980s and 90s
1980s and 90s
1980s and 90s
Oliver Wendell Holmes, Sr. comes up with the word “anesthesia”:
Borrowing from the Greek word for senseless, the American physician and polymath coined the word “anesthesia” to refer to the process of using ether to anesthetize a patient during a surgery he publicly performed.
Jean-Pierre Robiquet discovers codeine:
First identified by Frenchman Jean-Pierre Robiquet, codeine provides doctors with a less powerful form of opium that can be synthesized. This is a welcome discovery as British opium consumption hits record highs.
Friedrich Sertürner makes morphine:
This German scientist is the first to isolate morphine, the active ingredient in opium. Sertürner dissolves opium in acid and then neutralizes it with ammonia. Morphine, a very powerful painkiller, is ten times stronger than opium. The drug is widely used as a painkiller during the U.S. Civil War (1861–1865).
Laudanum becomes popular in England:
English physician Thomas Sydenham develops a proprietary opium tincture, a simplified version of the laudanum of Paracelsus.
Paracelsus invents laudanum:
A German-Swiss alchemist, Paracelsus mixes opium in an alcoholic solution and dubs it laudanum; it’s widely circulated in European medical literature as a painkiller.
Traders bring opium to Asia:
Arab traders introduce opium to China. Opium is cultivated in East Asia on and off for the next 1600 years, though its use is considered immoral in Eastern medicine.
Theophrastus writes about opium:
Historians note that the Greek philosopher’s reference to the milky juice of an opium poppy to relieve pain is the first confirmed record of opium use.
Hippocrates recommends willow bark for pain:
The Greek physician advises chewing willow bark to help relieve pain and reduce fever. He also advises consuming tea made from the bark of the willow to help relieve pain after childbirth.
+
1846
1846
1846
+
1830
1830
1830
+
1803
1803
1803
+
1676
1676
1676
+
1500s
1500s
1500s
+
400 AD
400 BC
400 AD
+
300 BC
300 BC
300 BC
+
400 BC
400 BC
400 BC
The History of Pain Management
Doctors are careful to send patients home with no more than a three-day supply of medication, usually over-the-counter pain medications like acetaminophen or ibuprofen, completely eliminating the need for opioids.
This necessary change has been made possible, in large part, to the advent of nerve blocks. The numbing effect, while a minor inconvenience, gives the body a 24-to-36-hour head start on the healing process. Considering that 3–4% of those who use opioid pain killers become addicted, the rise of nerve blocks will most certainly save lives.
ED staff at Staten Island University Hospital are trained to administer nerve blocks.
Northwell’s Staten Island University Hospital begins using nerve blocks for hip fractures in its Emergency Department (ED).
The blocks are administered with the guidance of ultrasound, greatly lessening the ED’s dependence on opioids and potentially ending their use altogether in the future.
+
2022 and beyond
2022 and beyond
2022 and beyond
+
September 2022
September 2022
September 2022
+
2021
2021
2021
Health systems around the country begin looking for alternatives to opioids.
Northwell Health, led by senior vice president for Northwell's anesthesia line, Joseph Marino, MD, introduces the use of nerve blocks in emergency care with the goal of taking it system-wide; Dominick Gadaleta, MD, David Pechman, MD and Andrew Bates, MD at Northwell’s South Shore University use nerve blocks during bariatric surgery. Northwell surgeons see massive benefits for patients, with quicker recovery, less pain and less exposure to opioids. Patients also avoid the physical side effects of opioid-based anesthesia, such as nausea and breathing issues.
Opioid addiction skyrockets in the U.S. due to overprescribing and overreliance on medical pain killers
Patients coming in for a procedure such as knee surgery go home with a three-month supply of oxycodone — 180 pills — despite only needing enough for three days. Huge vials of narcotics fill medicine cabinets across the U.S. Overdose deaths involving prescription opioids jump from 3,442 in 1999 to 17,029 in 2017. Overall, opioid-involved overdose deaths more than double in seven years: from 21,088 in 2010 to 47,600 in 2017. (Source: https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates)
FDA Amendments Act:
FDA Amendments Act granted FDA authority to require specified safety measures known as Risk Evaluation and Mitigation Strategies for certain drugs, but the FDA won’t act decisively on opioids for pain management until 2013.
+
2020s
2020s
2020s
+
2000–2018
2000–2018
2000–2018
+
2007
2007
2007
As overdose deaths begin to skyrocket, FDA sends a warning letter to OxyContin manufacturer for misleading advertising.
Pain is labeled the 5th vital sign
Pain experts lobby to include pain alongside body temper ature, pulse rate, respiration rate and blood pressure as a vital sign that doctors must monitor and manage. This had the unintended consequence of striving for a goal of zero post-surgical pain.
Diagnostic ultrasound is used to administer nerve blocks more effectively.
+
2003
2003
2003
+
2001
2001
2001
+
2000s
2000s
New painkillers marketed as “non-addictive” come to market with approval from the Food and Drug Administration (FDA):
Vicodin in 1984, OxyContin in 1995, Actiq (fentanyl) in 1998, and Percocet in 1999.
Nerve blocks enter common treatment:
Neuraxial nerve blocks like epidurals become commonplace during childbirth and in surgeries when a patient is deemed a poor candidate for traditional anesthesia.
+
1980s and 90s
1980s and 90s
1980s and 90s
+
1980s
1980s
1980s
Mayo Clinic surgeons use regional nerve blocks:
Mayo Clinic further develops peripheral and neuraxial nerve blocks (like epidurals), which block pain to a limb or groin, allowing physicians to ease pain during labor and surgeries.
U.S. bans opium:
In response to alarming rates of heroin addiction, the U.S. enacts the Smoking Opium Exclusion Act, effectively banning opium dens.
August Gustav Bier develops regional anesthesia:
The German surgeon finds a way to achieve intravenous regional anesthesia, allowing a patient to be awake during surgery without feeling pain from the site of the surgery.
+
1925–1940
1925–1940
1925–1940
+
1909
1909
1909
+
1908
1908
1908
William Steward Halsted tries nerve blocks for anesthesia:
An American surgical pioneer, Halsted invents nerve blocks by injecting cocaine into the nerve trunk.
A chemist stumbles upon heroin:
Attempting to create a less addictive form of morphine, English chemist C.R. Wright makes heroin by boiling morphine on a stove. Bayer later commercializes heroin for medical use at the turn of the century.
Scientists in Germany and UK invent syringes:
The first reliable syringes are developed. Injected morphine becomes the standard method of reducing pain during and after surgery.
+
1885
1885
1885
+
1874
1874
1874
+
1853
1853
1853
Oliver Wendell Holmes, Sr. comes up with the word “anesthesia”:
Borrowing from the Greek word for senseless, the American physician and polymath coined the word “anesthesia” to refer to the process of using ether to anesthetize a patient during a surgery he publicly performed.
Jean-Pierre Robiquet discovers codeine:
First identified by Frenchman Jean-Pierre Robiquet, codeine provides doctors with a less powerful form of opium that can be synthesized. This is a welcome discovery as British opium consumption hits record highs.
+
1846
1846
1846
+
1830
1830
1830
Friedrich Sertürner makes morphine:
This German scientist is the first to isolate morphine, the active ingredient in opium. Sertürner dissolves opium in acid and then neutralizes it with ammonia. Morphine, a very powerful painkiller, is ten times stronger than opium. The drug is widely used as a painkiller during the U.S. Civil War (1861–1865).
Laudanum becomes popular in England:
English physician Thomas Sydenham develops a proprietary opium tincture, a simplified version of the laudanum of Paracelsus.
Paracelsus invents laudanum:
A German-Swiss alchemist, Paracelsus mixes opium in an alcoholic solution and dubs it laudanum; it’s widely circulated in European medical literature as a painkiller.
+
1803
1803
1803
+
1676
1676
1676
+
1500s
1500s
1500s
Traders bring opium to Asia:
Arab traders introduce opium to China. Opium is cultivated in East Asia on and off for the next 1600 years, though its use is considered immoral in Eastern medicine.
Theophrastus writes about opium:
Historians note that the Greek philosopher’s reference to the milky juice of an opium poppy to relieve pain is the first confirmed record of opium use.
Hippocrates recommends willow bark for pain:
The Greek physician advises chewing willow bark to help relieve pain and reduce fever. He also advises consuming tea made from the bark of the willow to help relieve pain after childbirth.
+
400 AD
400 BC
400 AD
+
300 BC
300 BC
300 BC
+
400 BC
400 BC
400 BC
The History of Pain Management
At South Shore University Hospital, the transition away from opioids is spreading from bariatric surgeries to C-sections to ultrasound-guided usage in emergency departments. Like many successful innovations, it began with a change in perspective. Opioids treated a symptom; nerve blocks address the cause.
“Understanding basic anatomy and where the pain comes from is really the first key,” said Dr. Gadaleta of the shift. “If we can block pain and we do this with our anesthesia colleagues at its source at the nerve level, the patient does not experience pain. But the other thing is to have your colleagues, nursing staff and the entire team including the patient understand what pain really is. And it turns out we were treating other conditions with pain medication and oftentimes the opioids were making the conditions we were trying to treat worse.”
Dr. Gadaleta describes a common scenario in which a patient experienced bloating caused by the body’s natural stress response to surgery. Opioids were typically prescribed to address the pain caused by the bloating, but instead of helping, opioids increased the patient’s suffering.
Using nerve blocks in addition to preemptive medications goes a long way toward eliminating the pain before it starts by addressing it at its root cause.
The transition away from opioids at South Shore University Hospital has been swift and effective. After the program’s implementation in the bariatric program less than three years ago, the number of opioids used postoperatively fell to nearly zero within a couple of months. Now Dr. Pechman describes the presence of opioids as “virtually absent.”
From a patient perspective, the fact that the opioid epidemic has touched lives across all sectors of American life has made this transition to alternative pain management most welcome.
“Patients are really happy to hear that they will not need opiates in our program,” said Dr. Pechman. This is great news for Northwell patients, but Dr. Gadaleta isn’t satisfied.
To scale the program at a national level will require a multifaceted approach that includes awareness campaigns for patients and education at all levels of nursing and medical schools, as well as the expansion of pilot programs across the nation’s health care systems.
Yet Dr. Gadaleta is quick to point out that even the smallest reduction in the use of opioids has positive implications. For example, patients with chronic pain may come to the hospital using opioids.
Using nerve blocks during surgery may not eliminate their opioid use, but leaving the hospital without increasing usage is still a win. “Even if we can get the number of opioids prescribed from 30 to five, I think we’re doing good work,” said Dr. Gadaleta. “We can’t discourage people that need that crutch, but I want to see the day where it’s zero across the board.”
Using an innovative pain management technique called nerve blocks, Drs. Gadaleta and Pechman have turned the status quo of bariatric surgery on its head. No longer are patients requiring long recoveries in hospital or being prescribed 15-30 opioids to manage pain. Now, patients recover quickly and only need traditional acetaminophen (Tylenol) to mitigate the painful side effects of surgery. Gone are the troubling side effects of opioids and the risk of addiction. It’s a transition that will most certainly save lives.
“What we saw when we ceased prescribing opioids to manage postoperative pain,” said Dr. Gadaleta, “was shorter length of stay, quicker recovery and better patient satisfaction.”
Though Northwell’s deployment of nerve blocks is part of a new and growing movement to reduce opioid use in ORs, nerve blocks themselves aren’t new. Most people have heard of an epidural, a type of neuraxial nerve block commonly used during childbirth. Along with traditional anesthesia, nerve blocks have been used in various capacities since 1885 when American surgical pioneer William Stewart Halsted invented them by injecting cocaine into the nerve trunk.
Nerve blocks act like a local anesthetic, numbing the nerves at a specific site for a specific amount of time. For example, using a nerve block at the site of a surgical incision prevents pain in the immediate aftermath of a procedure. Because pain doesn’t last forever ― it lessens every hour after surgery ― nerve blocks give patients a head start on recovery. The result is wonderfully effective: by preventing pain at the nerve site, a patient requires less pain management. As the nerve block gradually wears off, the pain threshold is greatly reduced from its apex. Instead of requiring Percocet or other opioids to manage the pain, a patient can now recover with over-the-counter pain medications such as acetaminophen or ibuprofen, completely eliminating the need for opioids.
Dr. Pechman was quick to point out that ditching opioids in the OR doesn’t mean patients are left to white-knuckle through their pain post-op. “We’re not withholding medication that the patients need,” said Dr. Pechman on the same 20-Minute Health Talk episode. “We do such a good job of multimodal pain therapy that the patients do not need those medications. And then if we can avoid the downstream effects of slower bowel motility, some patients will experience severe nausea or itchiness. Little things like that can become big things, then cause other issues. So if we can really eliminate all those downstream problems and let patients spend less time in the hospital and feel better, it’s really a win-win.”