The Cocktail For Long Lasting Local Anesthesia: Mitigating Chronic Post-Surgical Pain

Swirling the opaque garnet wine around the edges of the Riedel glass allowed for the complex interaction of its fruit to escape from its mixture. After the wine hit the palate, I knew due to the structure, mouth feel and astringency that this was a superior blend of high grade, very stressed berries of different varieties. I would need more exploration to attempt forensic identification but so be it. Someone has to do some work. Interestingly, while I was enjoying this Meritage, I began to ponder how there has been this evolution in the wine industry from a decade or two ago when everything was all about single varietals. The true wine snobs would only cherish those pure Cabernets or Merlots. Mix them together and it was outright heresy. Now, with the advent of titans like Super Tuscans, the boldness of the Aussies violating all “French rule” and mixing together whatever they wanted to, winemakers had somehow seen the light: blends. Yes, by blending that Cabernet with that Shiraz, something happened that was greater than either could be alone. Some would say it was like listening to a full-blown orchestral concert versus a simple horn concerto. All of a sudden, wine aficionados started to get it. Blends were cool and damn good juice at that. The simple fact is that mixtures rule supreme in many cases and that indeed is the case with liposomal bupivacaine. One may ask: what is a liposome? Those who are reading this should probably not have to ask what bupivacaine is. If you do, hide your face, look around you, make sure no one sees you reading this and finish that application for business school. A liposome is a nifty little molecule that a hematologist named Alec Bangham, MD, first developed way back in 1961. Think of it as a little ball of fat (a phospholipid bilayer to be exact) into which one can put some other molecules such as drugs. Now by being encased in this phospholipid sphere, the drug has protection from degradation or metabolism until it no longer is encased in its little fatty coat, and scientists can play with the pharmacodynamics of any substance they put inside it. A great example of this tricky little scientific scheme is Exparel (Pacira Pharmaceuticals). As an amide local anesthetic, bupvicaine is known to be one of the longer lasting agents, giving four to six hours of bliss from pain, only perhaps topped by its near cousin ropivacaine (Naropin, Fresenius Kabi USA). Package that little beauty of a molecule bupivacaine in its liposomal coat and we have got us a blend. As a hater and fighter of pain, and especially chronic post-surgical pain, I knew I had to “get me some” as my friend Tex would say. So I did. Now like the good juice swirling around in my glass, this liposomal cocktail is some really good juice as well and is becoming my favorite “beverage” to serve at the end of a surgical case. Patients dislike pain immensely enough that they have pain oftentimes just thinking about pain. Now by using something that gives up to 72 hours of local anesthesia, your chances of having really happy patients go way up to almost certain. In addition to providing some of the absolute best postoperative pain management available in the galaxy, you may in fact just have decreased the likelihood of a patient developing chronic post-surgical pain. So what’s the chance of that happening? Ten percent and it may be higher than that.¹ You might say to yourself “that’s not bad” until you have to see those 10 out of 100 in the post-op clinic and fight a long-term battle to help these very severely affected patients, whose lives have been trashed by the painful scar neuroma or a chronically painful lateral ankle after a peroneal surgery. If you are an average practitioner, you will do about 300 surgical procedures in a year and that means you could end up with 30 folks in the hurt locker. God forbid more than a couple show up on the same clinic day. Chronic post-surgical pain is pain lasting greater than two months post-surgery.¹ Now here is an interesting fact that has great applicability in preventing the development of chronic post surgical pain. The intensity of acute postoperative pain predicts the development of chronic post-surgical pain.² Do you get the subtlety here? Maybe you need to get some of this juice for when you bartend the next time you are in surgery. Most foot and ankle surgeons would agree that if you get patients past the first three days without much pain, their chances of having any substantive postoperative pain are minimal unless they do something stupid like try to hike on the 10th day after a hallux valgus reconstruction. So now we have a vehicle we can use to make patients more comfortable in that immediate postoperative period; reduce their intake of opioids, which screw up sleep and bowels; and perhaps prevent the development of chronic post-surgical pain. That is some powerful weapon for the surgeon to have. There initially was some pushback to the cost of the medication but reimbursement in the ambulatory surgical center setting is no longer problematic. At least this is the case at our center and I believe that is the case throughout the nation. Even so, if I were the patient, I would be willing to pay extra for it and I have found that to be the case with my patients. Patients will pay for things if you just ask them. If you can offer them something like this, they will be all over it like a big bass on a top water lure. If you want a local anesthetic, which, like great wines, has a big finish and hangs on that back palate for a long time, think about Exparel. Go get you some. Financial disclosure: I have no financial relationship or consulting relationship with Pacira Pharmaceuticals or its product Exparel. References 1. Carroll I, Hah J, Mackey S, Ottestad E, Kong JT, Lahidji S, Tawfik V, Younger J, Curtin C. Perioperative interventions to reduce chronic postsurgical pain. J Reconstr Microsurg. 2013; 29(4):213-222. 2. Gerbershagen HJ, Ozgur E, Dagtekin O, Straub K, Hahn M, Heidenreich A, Sabatowski R, Petzke F. Preoperative pain as a risk factor for chronic post-surgical pain - six month follow-up after radical prostatectomy. Eur J Pain. 2009; 13(10):1054-1061.