♪ ♪ >> IF YOU ARE SCHEDULED FOR A SURGICAL PROCEDURE AND LIKE MANY OF US, YOU ARE WORRIED ABOUT POST-OP TIFF PAIN AND YOUR OPTIONS FOR CONTROL.

STAY WITH US AS WE TALK WITH SPINE SURGEON Dr. JEFFREY GUM ABOUT THE NOVEL AND TRIED AND TRUE WAYS TO CONTROL PAIN WITHOUT OPIOIDS NEXT ON "KENTUCKY HEALTH."

>> "KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT FROM THE FOUNDATION FOR A HEALTHY KENTUCKY.

>> WHETHER IT IS ELECTIVE, URGENT OR EMERGENCY, SURGERY PATIENTS HAVE MANY CONCERNS.

THESE CONCERNS INCLUDE THE NEED FOR TRANSFUSION, IMPACT ON QUALITY OF LIFE, POSSIBLE FUNCTIONAL LIMITATIONS, A NEED FOR REHABILITATION AND FOREMOST HOW MUCH PAIN TO EXPECT AND HOW WILL IT BE ADDRESSED.

TO MY KNOWLEDGE THERE IS NO DEVICE THAT PROVIDES AN OBJECTIVE MEASURE OF THE DEGREE OF PAIN THAT ONE IS EXPERIENCING.

HOWEVER, THERE ARE SEVERAL TOOLS TO SUBJECTIVELY MEASURE ONE'S PAIN LEVEL, BUT THEY ARE FLAWED AND BIASED BY HOW EACH OF US PERCEIVES PAIN, LEVEL OF TOLERANCE AND IN SOME CASES BY THE OBSERVER THEMSELVES.

WE DO KNOW THAT PATIENTS WHO EXPERIENCE SIGNIFICANT ACUTE PAIN IN THE EARLY POST-OPERATIVE PERIOD RECOVER SLOWER, TEND TO HAVE MORE POST-OPERATIVE COMPLICATIONS, ARE IMPORTANT LIKELY TO EXPERIENCE CHRONIC POST-OPERATIVE PAIN AND TEND TO HAVE A LOWER QUALITY OF LIFE.

OH YES, AND EVERYBODY FROM THE PATIENT, THE PROVIDER, THE HOSPITAL AND THE PHARMACIST ARE TERRIFIED ABOUT USING OPIOIDS.

SO IF YOU DON'T WANT TO USE OPIOIDS, WHAT IS LEFT FOR THE WELL MEANING PROVIDER TO DO?

TODAY'S GUEST Dr. JEFFREY GUM IS GOING TO TELL US ABOUT BETTER USE OF OPIOIDS, AND NON-OPIOID MEDICATIONS, DIFFERENT WAYS TO UTILIZE AND DELIVER FAMILIAR THE UNDERGRADUATE AND MEDICAL THE UNDERGRADUATE AND MEDICAL SCHOOLS AT THE UNIVERSITY OF KANSAS IN LAWRENCE, KANSAS.

HE COMPLETED AN ORTHOPAEDIC SURGERY RESIDENCE AT THE UNIVERSITY OF LOUISVILLE FOLLOWED BY AN ORTHOPEDIC SURGERY OF THE SPINE FELLOWSHIP AT WASHINGTON UNIVERSITY IN ST. LOUIS, MISSOURI ON STAFF AS SPINE SURGEON WITH NORTON LERDZMAN SPINE IN LOUISVILLE AND A PROFESSOR AT THE DEPARTMENT OF ORTHOPAEDICS AT THE UNIVERSITY OF LOUISVILLE.

Dr. GUM, JEFF, THANKS FOR BEING WITH US TODAY.

>> THANK YOU.

>> WHAT DOES A GOOD SPINE DOCTOR DOING TALKING ABOUT PAIN?

>> THAT'S A GREAT QUESTION.

I THINK IT STARTS WITH WHERE WE LIVE, RIGHT, THIS PART OF THE COUNTRY HAS HAD A HUGE ISSUE WITH OPIOIDS.

NUMBER TWO, PAIN CONTROL IS A BIG PART OF SPINE SURGERY.

SO WE INFLICT PAIN WHEN PATIENTS UNDERGO THE SURGICAL PROCEDURE, BUT WE ALSO DO THE SURGERY TO HELP GET RID OF SOME OF THAT PAIN.

>> YOU KNOW, AS A COLORECTAL SURGE SURGEON, THE PATIENTS NEVER HAVE PAIN-- >> I KNOW THAT'S NOT TRUE.

>> SO TELL ME WHEN WE THINK ABOUT PAIN, DOES IT HAVE A FUNCTION?

>> YEAH, IT ACTUALLY DOES.

YOU KNOW, A LOT OF THE CONVERSATION I HAVE WITH PATIENTS IN THE OFFICE IS PAIN LETS YOU KNOW IF YOU ARE DOING SOMETHING WRONG, RIGHT?

OR SOMETHING IS WRONG WITH YOUR BODY.

SO IT DOES HAVE A FUNCTION.

IT DOES HELP US, RIGHT?

AND THERE ARE LOTS OF DIFFERENT TYPES OF PAIN.

SO THERE IS PAIN FROM NERVES BEING PINCHED, ARTHRITIC PAIN FROM JOINTS WEARING OUT.

ALL SORTS OF DIFFERENT PAINS.

I THINK THAT'S WHAT IS IMPORTANT FOR PATIENTS TO UNDERSTAND.

>> WHAT IS THE MECHANISM OF PAIN?

WHAT IS ACTUALLY GOING ON WHEN SOMEONE HAS PAIN?

>> YEAH, GREAT QUESTION.

SO THE BIG THING IS WHATEVER IS CAUSING IT, RIGHT?

SO SAY IT'S A KNEE JOINT WORN OUT.

IT SENDS A SIGNAL TO THE BRAIN AND YOUR BRAIN INTERPRETS THAT SIGNAL AS THAT IS NOT GOOD SO THERE IS PATHWAYS FROM EITHER JOINTS OR NERVES OR THINGS LIKE THAT THAT SEND THE SIGNALS TO THE BRAIN.

AND THAT'S WHY YOUR BRAIN INTERPRETS IT AS PAIN.

>> AND IS IT SOMETHING THAT, SAY HEY SH DON'T DO THIS ANYMORE?

AND WE SHOULD STOP?

>> THAT'S A BIG PART OF IT.

IT'S LIKE IF YOU PUT YOUR HAND ON A STOVE OR SOMETHING LIKE THAT, IT'S TELLING YOUR BODY TO GET IT OFF THE STOVE.

>> THAT'S A GOOD POINT.

DO IT ONCE AND YOU LEARN THE LESSON FOR THE REST OF YOUR LIFE.

>> DON'T DO IT AGAIN.

>> TELL ME ABOUT SOME OF THE TRADITIONAL THINGS, YOU KNOW, AS WE LOOK AT THROUGH AGES, HOW WE START AVOIDING OR TREAT MANAGING PEOPLE WITH PAIN.

>> SO TYLENOL HAS BEEN AROUND A LONG TIME.

>> WHAT IS THAT?

>> ACETAMINOPHEN.

THAT'S A PAIN RELIEVER, ALSO REDUCES FEVERS, IT'S NOT AN ANTIINFLAMMATORY MEDICATION LIKE ADVIL, ALEVE, THOSE KINDS OF MEDICATIONS OVER THE COUNTER, BUT TRADITIONALLY, THE BIG HEAVY HITTER FOR PAIN CONTROL AND WHAT THE PUBLIC THINKS ABOUT IS OPIOIDS OVER THE LAST 30 YEARS HAS BEEN A BIG ISSUE.

WE HAVE SEEN THE DETRIMENTAL EFFECTS OF THAT AND THE AMOUNT OF OPIOIDS TRE SCRIBED GO THROUGH THE ROOF OVER THE LAST 20 TO 30 YEARS.

>> I'M GOING TO BACK TRACK FOR A MOMENT.

YOU ARE A SURGEON AND I ALLUDED TO IT IN THE BEGINNING.

I THINK THIS IS A DISCUSSION WE HAVE TO HAVE WITH PATIENTS ABOUT PAIN.

>> YEAH.

>> WHAT DOES THAT LOOK LIKE.

TELL ME WHAT ARE THE THINGS THAT YOU ARE DISCUSSING?

>> SO THE FIRST THING IS I TELL FOLKS, YOU ARE GOING TO HATE ME FOR ABOUT A MONTH AFTER THE SURGERY WE DO.

AND THAT'S MAYBE A LITTLE DRAMATIC OUGHT AT LEAST IT'S LETTING THEM KNOW THAT WHEN WE ARE COUNSELING FOLKS ON SURGERY, ESPECIALLY SPINE SURGERY, IT'S NOT ALL-- IT'S GOING TO BE ROUGH TO START WITH, RIGHT?

SO MOST SPINE SURGERY IS PRETTY INVASIVE.

SOME OF THE STUFF I DO IS FROM SKULL TO YOUR TAIL BONE, AND THAT'S A BIN INCISION AND HARD TO RECOVER FROM.

THE FIRST THING, I TRY TO SET EXPECTATIONS FOR THEM OF WHAT THEY'RE GOING TO GO THROUGH, ALL RIGHT.

AND THEN AFTERWARDS, I TRY TO EXPLAIN TO THEM THE DIFFERENT WAYS WE ARE GOING TO HELP CONTROL THAT PAINMENT AND OPIOIDS, THE THING IS OPIOIDS HAVE A BAD RAP FOR A GOOD REASON NOW.

I THINK THEY WERE OVERPRESCRIBED AND OVER UTILIZED.

THE BIG THING IS YOU JUST NEED TO UNDERSTAND WHAT YOU ARE GETTING YOURSELF INTO.

THOSE MEDICATIONS ARE REALLY GOOD FOR ACUTE PAIN, SURGERY, FRACTURES, SOMETHING LIKE THAT.

BUT THEY'RE NOT VERY GOOD FOR CHRONIC PAIN AND THAT'S THE BIG ISSUE WHERE WE FOUND OURSELVES TODAY.

>> BUT IF I'M HAVING THIS AND I TAKE THIS AND IT TAKES AWAY THE PAIN, HOW ARE YOU GOING TO CONVINCE ME NOT TO DO THAT.

>> I'M NOT TRYING TO CONVINCE YOU NOT TO.

I'M TRYING TO EDUCATE YOU TO HAVE REALISTIC EXPECTATIONS AND THE TIMELINE.

TYPICALLY WE DO A SURGERY AND PATIENTS WILL NEED OPIOIDS TO START WITH AND WE TAPER THEM OFF AND THE THING IS UP FRONT TO EXPLAIN TO THEM, THAT A REALISTIC TIME TIMEFRAME.

I'LL TELL FOLKS, A SMALL PROCEDURE MAYBE A WEEK OR TWO TO UTILIZE THOSE TYPES OF MEDICATIONS BUT THE OTHER THING IS TO USE OTHER MEDICATIONS THAT CAN HELP.

>> ALL RIGHT.

SO YOU ARE DISCUSSING THIS PROBLEM ABOUT POSSIBLE PAIN WITH THE PATIENT PREOPERATIVELY.

WHAT ARE SOME OF THE THINGS YOU CAN TELL THE PATIENT THAT THEY CAN DO OTHER THAN USING OPIOIDS TO TRY TO CONTROL SOME OF THE PAIN, THINGS THAT-- ACTIVITY OR MIND SET.

>> SO BOTH OF THOSE ARE GREAT THINGS.

ONE, UNDERSTANDING THAT YOU ARE GOING TO HAVE SOME PAIN, AND PAIN FREE IS NOT A REALISTIC EXPECTATION I TELL FOLKS THE MORE ACTIVE YOU ARE, THE FASTER YOU RECOVER.

SO ACTIVE IS GOOD CERTAIN RESTRICTIONS BUT WE WANT YOU MOVING AROUND.

A POSITIVE MIND SET HELP FROM A PAIN CONTROL PERSPECTIVE.

I DON'T BANT TO PRESUME THAT PAIN IS IN THE MIND OF THE INDIVIDUAL THERE ARE DIFFERENT AGREES TO WHICH PEOPLE EXPERIENCE PAIN MERE IN THE UNITED STATES AND ACROSS THE WORLD WHY IS THAT?

>> I THINK IT'S EXPECTATION AND THAT'S A GREAT POINT WE HAVE DONE A COUPLE STUDIES LOOKING AT OPIOID USAGE RIGHT, ACROSS THE WORLD.

SO ONE STUDY WAS 1 CENTERS ACROSS THE WORLD AND THERE WAS A HUGE DIFFERENCE IN OPIOID CONSUMPTION IN ASIAN COUNTRIES.

SO CANADA, U.S., EUROPE, HAD ABOUT THREE TIMES MORE OPIOID CONSUMPTION AFTER THESE TYPES OF PROCEDURES.

AND I THINK THAT'S ALL EXPECTATIONS, RIGHT?

THAT'S THE CULTURAL PERCEPTION AND EXPECTATIONS, WHICH IS A GOOD POINT.

IN UNDERSTANDING THAT ALLOWS US TO TACKLE THIS MORE EFFECTIVELY.

>> OKAY.

LET'S START OFF THE STANDARD MEDICATIONS THAT A PATIENT USE.

SO YOU MENTIONED ABOUT TYLENOL A MOMENT AGO.

>> YEP.

>> LET'S GO TYLENOL, ASPIRIN, ALL THE NON-OPIOID MEDICATIONS.

>> CORRECT.

>> SO HOW DO YOU USE THOSE?

WHAT ARE SOME OF THE MECHANISMS.

>> GREAT QUESTION.

N FLSAIDS A WHOLE CLASS OF ANTIINFLAMMATORY MEDICATIONS, ADVIL, ALEVE, THE TRADE NAMES BUT THAT CLASS IS FANTASTIC AT REDUCING INFLAMMATION AND PAIN.

THE BAD THING, IT IS NOT THE BEST FOR YOUR KIDNEYS TORE TAKE LONG-TERM.

AS WE GET WISER, OR OLDER IT'S NOT THE BEST FOR YOU AS WELL.

THE OTHER THING IN SPINE SURGERY, A LOT OF WHAT WE DO IS SPINAL FUSION AND IN THE PAST, WE HEAR ABOUT THE NSAID BEING BAD OR DETRIMENTAL TO THE FUSION.

WE ARE STARTING TO INCORPORATE THOSE A LITTLE MORE POST-OP TO HELP WITH PAIN.

NSAIDS ARE A BIG PLAYER FOR PAIN CONTROL.

AND WHAT WE ARE DOING TO IS A REGIONAL BLOCK.

WHAT THAT IS IS BEFORE THE PROCEDURE, WE'LL GIVE YOU LOCAL ANESTHETIC IN THE AREA THAT WE ARE GOING TO WORK ON SO IF YOU ARE GOING TO HAVE FOOT AND ANKLE SURGERY, THEY WILL BLOCK THE NERVES TO THAT EXTREMITY AND THAT HASN'T BEEN HEAVILY USED IN SPINE UNTIL RECENTLY.

>> SO WHEN YOU ARE DOING A BLOCK, WHAT KIND OF MEDICATION ARE YOU USING?

ARE YOU USING A NARCOTIC FOR THIS PATIENT OR NON-NARCOTIC.

>> NON-NARCOTIC.

SO WE ARE USING A LOCAL ANESTHETIC.

THINK ABOUT GETTING YOUR TOOTH PULLED.

THE DENTIST IS GOING TO GIVE YOU A LOCAL ANESTHETIC.

LIDOCAINE IS A GOOD EXAMPLE.

AND WE USE MEDICATIONS LIKE THAT IN THE BLOCK.

>> AND AGAIN, YOU ARE JUST-- THE NAME IMPLIES, BLOCKING THE NERVE SO THAT IMPULSE OF PAIN IS NOT BEING TRANSMITTED UP AND YOU ARE NOT PERCEIVING IT.

>> CORRECT.

AND THAT TYPICALLY GIVES PATIENTS ANYWHERE FROM 12 TO A COUPLE DAYS WORTH OF RELIEF.

>> WHY NOT JUST SEND THE PATIENT HOME WITH A BLOCK?

>> GOOD QUESTION.

THOSE MEDICATIONS DON'T LAST THAT LONG.

AND THERE ARE SOME CENTERS THAT WILL TRY TO USE LIKE PUMPS OR THINGS LIKE THAT.

BUT THOSE ARE CUMBERSOME.

WE HAVEN'T GONE DOWN THAT PATHWAY YET FOR THE SPINE.

>> YOU FIND THOUGH THAT WHEN THE PATIENT DOES GET THIS BLOCK, YOU DON'T FROM-- YOU DON'T HAVE TO USE AS MUCH NARCOTIC FOR THE PROCEDURE.

>> DURING THE PRODUCER AND AFTERWARDS, CORRECT.

SO WHEN WE FIRST STARTED USING BLOCKS AT OUR CENTER, WE WERE DOING THEM AFTER THE PROCEDURE.

AN THEN ONCE WE STARTED TO DO IT BEFORE, WE REALIZED THAT DURING THE PROCEDURE IT WAS A LOT EASIER TO MAINTAIN THE PAIN CONTROL.

>> SO YOU MENTIONED ABOUT PERIPHERALLY.

>> YEP.

>> WHAT IS THE DIFFERENCE BETWEEN THAT AND AN EPIDURAL OR OTHER BLOCK.

IS THAT A TYPE OF BLOCK?

>> WELL EPIDURAL GETS THE NAME BLOCK BUT THAT'S REALLY A STEROID THAT GETS INJEKED NEXT TO A NERVE ROOT.

>> REALLY?

>> DURING SURGERY FOR SURGICAL PROCEDURES.

>> WE DON'T DO THAT DURING SURGERY.

>> BUT SOME OTHER TYPES OF SURGERY, AGAIN WOMEN WHO HAVE CESAREAN SECTIONS WILL HAVE IT DONE.

>> SO THAT NAME SHARES THE NAME -- SO AN EPIDURAL IS SPACE AROUND THE DUAS SACK.

AN EPIDURAL FOR PREGNANCY IS WHERE THEY INJECT LOCAL AND BASICALLY STOP THE FUNCTION OF THOSE NERVES COMPLETELY.

THERE IS NO MOTOR FUNCTION OR PAIN SENSATION.

EPIDURALS IN SPINE SURGERY WILL USE THE STEROID NEXT TO THE NERVE ROOT.

>> SO YOU MENTIONED ABOUT THE NSAIDS AND INFLAMMATION AND PAIN.

NOW YOU JUST TALKED ABOUT USING A STEROID IN SOMEBODY TO HELP BLOCK PAIN IF THEY HAVE BACK PAIN.

IS THE INFLAMMATION THE CAUSE OF THE PAIN AND IF YOU CAN GET RID OF THE INFLAMMATION, THERE IS NO PAIN.

>> THAT'S A VERY GOOD POINT.

SO THE WAY I EXPLAIN IT TO PATIENTS.

IF YOU TAKE A NERVE ROOT AND PINCH IT, THAT DOESN'T CAUSE PAIN.

SO IT WILL CAUSE NUMBNESS AND TINGLING IN THE DISTRIBUTION.

IF YOU PINCH IT LONG ENOUGH OR HARD ENOUGH AND IT GTS INFLAMED, THAT'S WHERE THE PAIN COMES FROM.

THAT'S WHY ESPECIALLY EPIDURAL BLOCKS WHERE THEY INSPECT STEROIDS NEXT TO THE NERVE ROOT HELPS QUITE A BIT.

>> WHEN YOU ARE TALKING ABOUT MANAGING A PATIENT'S PAIN POST-OP, ARE YOU TRYING TO INCORPORATE MORE ANTI-INFLANNELLER TO AGENTS?

>> WE ARE.

THE DATA ON THAT IS SHOWING THAT IT IS SAFER DURING FUSIONS NOWADAYS.

SO WE INCORPORATE THAT POST-OP IN THE HOSPITAL AND EVEN AS AN OUTPATIENT.

>> DO YOU GET INFLAMMATION WHEN YOU HAVE AN INFECTION AT A CERTAIN SITE?

>> YEAH, DO YOU.

THAT CAUSES A BIG INTHRAMMER TO CASCADE.

>> A ROLE FOR ANTIBIOTICS IS PARTS OF PAIN CONTROL.

>> NOT TO MY KNOWLEDGE, NOT YET.

>> I'M SURE SOMEBODY IS GOING TO COME UP AND TELL US.

>> SOMEBODY WILL FIGURE THAT OUT.

>> SO YOU HAVE THE PATIENT, YOU MENTION ALSO TYLENOL.

>> YES.

>> HOW ARE YOU GIVING THE TYLENOL TO HELP A PERSON AS FAR AS PAIN IN THE PERI OPERATIVE PERIOD?

>> IF THEY CAN TAKE IT ORALLY, WE GIVE IT TO THEM ORALLY BUT THERE IS ALSO I.V.

TYLENOL THAT IS RELATIVELY NEW.

HASN'T BEEN AROUND A LONG TIME BUT THAT HELPS AS WELL.

BUT OVERALL, THE BIG CONCEPT AT THAT TIME HAVE SPENT TIME IS ATTACKING PAIN THROUGH MULTIPLE PATHWAYS.

BEFORE THEY ROLL BACK FOR SURGERY, WE GIVE THEM SEVERAL ORAL MEDICATIONS, TYLENOL, MUSCLE RELAXER, GABA PENTIN THAT ATTACKS THE NERVES.

WE GIVE THEM MULTIPLE MEDICATIONS WHEN WE GIVE THEM-- WHEN THEY GO TO SLEEP, WE DON'T GIVE THEM OPIOIDS NOWADAYS.

IN A LOT OF OTHER CENTERS OR OTHER SURGERIES, WHEN YOU ARE ASLEEP, YOU GET TONS OF OPIOIDS AND THAT HELPS THE PAIN BUT THAT IMPAIRS YOUR RECOVERY.

IT IS HARD TO GET UP, CAUSES CONFUSION, DELIRIUM, G.I.

ISSUES, THINGS LIKES THAT.

SO WHAT WE HAVE FOUND BY CUTTING OUT THE OPIOIDS WHEN YOU ARE ASLEEP, PATIENTS RECOVER BERT AND QUICKER.

>> WHEN YOU COMPARE THE PATIENTS WHO HAVE OPIOIDS TO THE ONES WHO DIDN'T GET THE OPIOIDS, SAME DEGREE OF PAIN RELIEF?

>> NO.

ACTUALLY IF WE ATTACK IT THROUGH MULTIPLE DIFFERENT PATHWAYS, THEY GET BETTER PAIN RELIEF.

SO YOU CAN CUT OUT THE OPIOIDS WHEN YOU ARE ASLEEP, REDUCE IT POST-OP AND YOU STILL HAVE BETTER PAIN CONTROL IF YOU ATTACK IT FROM MULTIPLE PATHWAYS.

>> SO YOU MENTION A LOT OF DIFFERENT MEDICATIONS, AGAIN ALL THESE THINGS GO IN ORAL AND I.V.

OR DO YOU PUT LOCAL INJECTIONS AT THE PLACES WHERE YOU ARE DOING THE SURGERY?

>> IF WE ARE DOING THE SURGERY, WE TYPICALLY DON'T PUT IT NEXT TO THE NERVE ROOTS BUT WE WILL BLOCK THE MUSCLES, RIGHT, AND THAT WILL HELP WITH PAIN CONTROL AFTERWARDS.

>> WHAT OTHER THINGS FOR THE PATIENT WHO YOU ARE DOING THESE PROCEDURES WOWT OPIOIDS.

WHEN YOU SEND THEM HOME, WHAT ARE YOU DOING FOR THEM?

>> TYPICALLY WE ARE TELLING THEM THAT AID STEROID EVERY NOW AND THEN COULD HELP.

THAT REDUCES INFLAMMATION.

WE USE A MUSCLE RELAXER.

IF YOU THINK ABOUT IT, SPINE SURGERY A LOT OF TIMES WE GO GO AND PEEL TISSUE OFF THE BONY SPINE AND THE MUSCLE SPASM QUITE A BIT AFTERWARDS.

WE INCORPORATE THAT.

AND NOW WE ARE STARTING TO USE NSAIDS AS WELL.

>> WHAT ARE YOUR GENERAL SURGERY COLLEAGUES SAYING TO YOU.

I SEE DOUG ALL THIS WILD STUFF AND YOUR PATIENTS SEEM TO BE HAPPIER THAN MINE.

HOW APPLICABLE IS THIS TO SOMEONE HAVING ABDOMINAL OR CHEST SURGERY?

>> IT'S THE OTHER WAY.

WE STOLE THE IDEAS FROM THEM.

IF YOU THINK ABOUT IT, A BLOCK INTERIORLY.

>> WHAT IS TAP.

>> TRANSVERSE ABDOMINAL PAIN.

THEY DO A BLOCK, INJECT LOCAL, AND THAT HELPS FOR ABDOMINAL PAIN WITH INCISIONS.

IT HAS BEEN USED FOR C-SECTIONS TRADITIONALLY.

WE DO A LOT OF SURGERY THROUGH THE FRONT AS WELL SO WE STOLE THAT IDEA AND WE STARTED USING THAT FOR SPINE SURGERY WHEN WE GO THROUGH THE FRONT.

>> I GASDZER-- I GATHER IT TAKES A GREAT DEAL OF COORDINATION BETWEEN YOU AND YOUR ANESTHESIOLOGY COLLEAGUES.

>> 100%.

AND I COULDN'T-- THE TEAM THAT WE WORK WITH AT OUR CENTER, THEY HAVE BEEN AMAZING.

THIS WHOLE PATHWAY WE HAVE GONE DOWN, COULDN'T DO IT WITHOUT THEM.

THERE HAVE BEEN A FEW FOLKS THAT HAVE REALLY HELPED PIONEER THE BLOCKS, PUTTING PEOPLE TO SLEEP WITHOUT THE OPIOIDS.

THAT'S A LOT OF EXTRA WORK.

THEY HAVE BEEN FANTASTIC TO WORK WITH.

>> TELL ME ABOUT SOME OF THE THINGS THAT PEOPLE CAN USE AT HOME.

THINGS LIKE A TINS UNIT, IS THAT AN EFFECTIVE MEANS OF CONTROLLING PAIN FOR A PERSON FOLLOWING SURGERY.

>> I WOULD NOT SAY THAT IS EFFECTIVE POST-OP.

A LOT OF FOLKS WILL USE TINS UNIT IN THE PHYSICAL THERAPY PROCESS IN THE PREOPERATIVE PHASE BUT POST-OP MOST OF THE TIME WE DON'T UTILIZE SOMETHING LIKE THAT.

>> WHAT IS THE ROLE OF REHABILITATION AS FAR AS PAIN CONTROL?

>> I THINK P.T.

OR PHYSICAL THERAPY IS VERY HELPFUL THAT THE DOS AND DON'TS, HOW TO BEND, TWIST, LIFT APPROPRIATELY AND THINGS LIKE THAT.

A LOT OF TIMES THAT IS INCORPORATED POST-OP AND THAT'S VERY HELPFUL.

>> WHAT ARE THE THINGS WHICH SOME PEOPLE HAVE TALKED ABOUT AS FAR AS PAIN CONTROL, IS USE OF MARIJUANA OR SOME OF THE DERIVATIVES.

HAVE YOU-- ARE YOU AWARE OF ANY ROLES WHERE THAT HAS HELPED IN SOME POST-OPERATIVE PAIN.

>> YEAH, SO THE GENERAL ORTHOPEDIC LITERATURE, TOTAL KNEES TOTAL HIPS HAS PRETTY GOOD DATA SAYING THAT CAN BE HELPFUL.

>> REALLY?

>> RIGHT.

AND IN KENTUCKY IT HAS BEEN DIFFICULT BECAUSE WE ARE A NON-MEDICAL STATE.

BUT I THINK THERE IS SOME POTENTIAL PROMISE THERE.

MY BIG THING IS IS IT SAFE?

OPIOIDS WE KNOW THAT OPIOIDS HAVE A HUGE ISSUE, RIGHT?

HUGE SIDE EFFECT PROFILE.

PEOPLE DIE EVERY DAY FROM OVER USES OF OPIOIDS.

AND TO MY KNOWLEDGE, THERE ARE NOT MANY PEOPLE THAT HAVE DIED FROM OVER USE OF T.H.C.

SO IN MY OPINION IF SOMETHING CAN HELP REDUCE OPIOID CONSUMPTION, I THINK IT'S WORTH LOOKING INTO.

>> AS YOU LOOK AT YOUR MEDICATIONS FOR A PERSON, TRADITIONALLY IF SOMEONE IS IN THE HOSPITAL-- AND I KNOW WE ARE DOING LESS AND LESS TIME PATIENTS ARE SPENDING IN THE HOSPITAL.

BUT HAVE YOU THIS THING WHERE IF YOU HAVE PAIN, YOU HIT THE BUTTON AND SOMEONE COMES IN AND GIVES YOU MEDICATION.

BUT IT IS AFTER THE PAIN HAS DEVELOPED FOR THAT INDIVIDUAL.

IS THERE A BETTER MODEL, SAY ROUND THE CLOCK TO TRY TO STAY ON TOP OF THE PAIN OR IS IT BETTER TO JUST WAIT FOR THE PERSON TO START COMPLAINING?

>> I THINK IT'S-- THERE IS AN ADVANTAGE TO STAY AHEAD OF IT, WITH CERTAIN MEDICATIONS ON A SCHEDULED BASIS.

SO GAB PIN TON AND TYLENOL, YOU HELP TAKE THOSE CONSISTENTLY IT HELPS.

SO THINGS YOU CAN TAKE CONSISTENTLY.

I'M NOT A HUGE FAN OF TAKING OPIOIDS CONSISTENTLY.

OTHER MEDICATIONS FOR SURE.

BUT NOT OPIOIDS.

>> WOULD YOU PUT THEM ON A SCHEDULE TO TRY TO SEE ABOUT TRYING TO CONTROL THINGS.

>> CORRECT.

>> DOES THAT SEEM TO WORK BETTER?

IF THERE IS AN ACUTE PAIN ISSUE, STAY AGO HEAD OF IT ON A SCHEDULED BASIS DOES HELP.

>> SO WE HAVE TALKED ABOUT A LOT AND EVERYBODY IS SCARED TO DEATH OF THEM.

ARE OPIOIDS REALLY BAD?

IS THERE VALUE FOR THEM?

>> THERE IS VALUE FOR THEM.

THEY WOULDN'T EXIST IF THERE WAS NO VALUE FOR THEM.

THE BIG THING IS UNDERSTANDING THE DETRIMENTAL SIDE EFFECTS OF THEM AND EDUCATION.

FOR ACUTE PAIN, SURGERY, RECOVERY PROCESS WHERE PAIN HAS BEEN INFLICTED, OPIOIDS ARE USEFUL, RIGHT?

THEY HELP.

THEY ALLOW YOU TO GET AROUND AND FUNCTION SOME BUT YOU INTO ED TO UNDERSTAND THAT YOU NEED TO WEAN OFF OF THEM AS SOON AS YOU CAN AND JUST USE THEM FOR ACUTE PAIN.

>> TELL ME ABOUT THE CONCEPTION SEPTEMBER OF ADDICTION.

DO YOU SEE IT OPIOIDS ONLY OR OTHER MEDICATIONS AND WHAT IS ADDICTION?

>> YEAH, SO ADDICTION IS REALLY A DEPENDENCE, RIGHT?

SO EITHER A PHYSICAL DEPENDENCE OR A MENTAL DEPENDENCE ON A MEDICATION.

AND ADDICTION IS ALL SORTS OF OTHER MEDICATIONS.

AND THE SPINE SURGERY WORLD IT'S TYPICALLY OPIOIDS THAT PATIENTS HAVE ADDICTION ISSUES WITH.

>> HOW SOON DOES IT COME?

>> IT'S DIFFERENT FOR DIFFERENT PEEP.

SOME PEOPLE HAVE GENETIC PROFILES WHERE IT SETS THEM UP TO TO BE MORE LIKELY TO BE ADDICTED AND HONESTLY, I THINK THAT'S A REALLY GOOD AREA FOR US TO START TO PURSUE TO UNDERSTAND SOMEBODY'S, THE WAY THEY METABOLIZE CERTAIN MEDICATIONS AND UNDERSTAND THAT THEY'RE HIGH RISK FOR AN ADDICTION POTENTIAL.

>> SO THERE IS A NEW MEDICATION THAT IS COMING DOWN THE PIKE.

>> YES.

>> AND WHAT CAN YOU TELL US ABOUT IT RIGHT NOW.

>> THE GREAT QUESTION.

I DON'T KNOW A TON ABOUT IT.

I KNOW CONCEPTUALLY WHAT IT DOES.

AND THE REASON I DON'T KNOW A TON ABOUT IT IS BECAUSE IT IS SO NEW.

GOT APPROVED BY THE FDA A COUPLE WEEKS AGO AND IT TOUTS THAT IT IS NOT ADDICTIVE, RIGHT AND HAS A VERY LITTLE-- >> WE'VE HEARD THAT BEFORE.

>> 100%, RIGHT?

AND THAT'S THE ISSUE, RIGHT?

AND SO I AM EXCITED.

I'M INTERESTED.

MY PATIENTS ARE GOING TO BE INTERESTED BUT AGAIN, ANY MEDICATION LIKE THAT, OR ANYTHING NEW, NEW TECHNIQUE, NEW TOY IN THE O.R., NEW MEDICATIONS I ADVOCATE TO GO SLOW WITH IT AND SEE WHAT THE DATA REALLY SHOWS.

SO WE WERE TOLD OXYCONTIN OR OPIOIDS WERE NOT ADDICTIVE, RIGHT?

OBVIOUSLY THAT WASN'T CORRECT.

BUT THIS NEW MEDICATION THAT IS PROMISED, IT DOESN'T ACT CENTRALRY, SO IT TURNS THAT SIGNAL OFF COMING FROM AN EXTREMITY OR SOMEWHERE ELSE IN THE BODY AND DOESN'T DO IT IN THE BRAIN.

IT DOES IT PERIPHERALLY.

>> HOW DOES IT DO THAT?

>> NOT EXACTLY SURE.

IT JUST DISRUPTS THE SIGNAL TO THE BRAIN AND IF YOU CAN KILL PAIN OR REDUCE PAIN FROM THAT PERSPECTIVE, IT IS A LOT LESS LIKELY TO BE ADDICTIVE.

>> BECAUSE THAT WAS THE DEAL WITH OPIOIDS.

NOT SO MUCH THAT IT BLOCKED THE PAIN.

IT JUST MADE YOU NOT CARE ABOUT THE PAIN.

>> CORRECT.

>> AND THEN YOU SAID WITH THE NSAIDS YOU ADDRESS THE INFLAMMATORY PROBLEMS WHEN HELPED CONTROL SOME OF THE PAIN.

>> YEP.

>> SO THIS IS JUST-- HOW DOES IT KNOW, OKAY, MY LEFT KNEE IS HURTING.

THEREFORE GO THERE AND-- >> IT TURNS OFF THE PAIN RECEPTOR OR BLOCKS THE PAIN RECEPTOR.

>> INTERESTING TO SEE-- THAT IS GOING TO COST A FORTUNE, I BET.

>> I THINK THE NEXT BARRIER IS WHAT IS IT REALLY LOOK LIKE AND REAL LIFE USAGE, TOO WHAT THE INSURANCE COMPANIES ARE GOING TO THINK ABOUT IT AND THIS THEY'RE GOING TO APPROVE IT.

A LOT OF TIMES NEWER MEDICATIONS THAT ARE GOOD AND EFFECTIVE ARE NOT CHEAP AND INSURANCE COMPANIES DON'T LIKE TO-- >> WHICH HAS BEEN THE CONUNDRUM I'VE ALWAYS FACED.

I CAN GIVE SOMETHING THAT AVOIDS USING AN OPIOID BUT NOBODY WANTS TO PAY FOR IT.

>> AGREE.

I THINK THERE IS A LITTLE BIAS AND CONFLICT OF INTEREST THERE IN CERTAIN FOLKS ARE NOT LOOKING OUT FOR THE WELL-BEING OF THE PATIENT, AT LEAST IN MY OPINION.

>> TAKE ME THROUGH WHAT GOES ON AT THE NORTON LEATHERMAN SPINE CENTER.

A PATIENT COMES IN, THEY HAVE A BAD BACKMENT YOU HAVE A DIIVELG PROBLEM.

I NEED TO GO IN AND OPERATE ON YOU.

YOU HAVE A DISC PROBLEM.

TAKE ME THROUGH THE PROCESS YOU ARE GETTING THIS PERSON READY MENTALLY TO GO FROM YOU ARE GOING HAVE THIS PAIN TO HOPEFULLY NOT HAVING ANY PAIN IN A MONTH.

WHAT DO YOU TELL THEM?

>> WELL ONE, EVERYBODY WANTS TO BE PAIN FREE, RIGHT?

>> YES.

>> AND DOES THAT HAPPEN?

IT DOES.

BUT I TELL FOLKS IF YOU ARE GOING TO END UP WITH A SPINE SURGERY, IF YOU HAVE A PROBLEM BAD ENOUGH THAT NEEDS SPINE SURGERY, THE GOAL IS TO REDUCE YOUR PAIN, RIGHT, TO MAKE IT MORE FUNCTIONAL WHERE YOU CAN LIVE YOUR DAY-TO-DAY LIFE AND DO THINGS YOU WANT WITH SOME PAIN AROUND, BUT REDUCED, RIGHT?

I TRY TO SET REALISTIC EXPECTATIONS.

WE TALK ABOUT PAIN CONTROL, WE TALK ABOUT THE DURATION OF OPIOID USE AFTERWARDS.

SO HOW LONG, RIGHT?

WHAT IS EXPECTED.

AND DEPENDING ON HOW INVASIVE THE SURGERY IS, IF WE ARE DOING SOMETHING THAT REQUIRES AN INCISION THIS BIG, IT'S COMMON TO BE ON OPIOIDS THREE OR FOUR WEEKS OR MAYBE A LITTLE LONGER, BUT THE GOAL IS TO GET OFF OF THEM SOONER RATHER THAN LATER.

IT STARTS WITH EDUCATION.

THAT'S NUMBER ONE.

NUMBER TWO, WHEN THEY COME IN FOR THE SURGERY, RIGHT BEFORE THEY ROLL BACK FOR THE SURGERY, THEY TAKE A LOT OF MEDICATION THAT IS NOT OPIOIDS MUSCLE RELAXERS, TYLENOL, THINGS LIKE THAT.

AGAIN WE ARE ATTACKING THE PAIN PATHWAY FROM MULTIPLE DIFFERENT ANGLES.

ONCE THEY GO INTO THE O.R.

WHETHER IT'S SURGERY FROM THE FRONT OR THE BACK, WE GIVE THEM A BLOCK.

ANESTHESIA TEAM INJEKS LOCAL ANESTHESIA.

THEY GO TO SLEEP AND DURING WHEN THEY'RE ASLEEP, THEY DON'T GET OPIOIDS.

AND WHAT IS INTERESTING ABOUT THAT, IS IN THE PAST WE USED TO GIVE PEOPLE TONS OF OPIOIDS, RIGHT?

THERE WAS REALLY NOT A HARD STOP ON THE AMOUNT OF OPIOIDS YOU COULD GIVE THEM AS LONG AS THEIR AIR WAY WAS PROTECTED.

BUT PATIENTS WOULD WAKE UP 15 YEARS AGO AND WOULDN'T REMEMBER ANYTHING FOR TWO WEEKS AFTER A SURGERY LIKE THAT.

SO WE DON'T GIVE THEM ANY OPIOIDS WHEN THEY'RE ASLEEP.

AFTERWARDS, WE PRESCRIBE IT FOR THEM.

IT'S THERE IF THEY NEED IT.

WE FOUND AFTER A BLOCK, THE FIRST 12 HOURS, PATIENTS ARE TAKING LESS OPIOIDS WITH MULTI-MODALITIES, MULTIPLE MEDICATIONS TO START WITH PLUS THE BLOCK.

>> FEELING BETTER AND THEY COME OUT AND SAY YOU KNOW, THAT Dr. GUM, HE DOES PAINLESS SURGERY.

>> I INDUCE PAIN.

I INDUCE PAIN.

BUT WE HAVE HAD FOLKS-- I HAVE HAD FOLKS THAT HAVE HAD SURGERY AT MULTIPLE DIFFERENT CENTERS.

THEY COME IN AND SAY WHATEVER YOU DID IS SO MUCH DIFFERENT.

IT'S NOT ME, IT'S MY ANESTHESIA TEAM.

>> JEFF, THANK YOU VERY MUCH FOR SHARING WITH US SOME OF THE THINGS GOING ON WHEN WE TALK ABOUT PAIN AND HOPEFULLY WE HAVE AN IDEA ABOUT THIS.

I WANT TO THANK YOU FOR BEING WITH US TODAY.

WE HAVE REASON TO BE CONCERNED ABOUT OPIOIDS, BUT FORTUNATELY IN MOST CASES WE ARE NOT RESTRICTED TO THIS CLASS OF DRUGS.

THERE ARE MANY OPTIONS FOR PAIN MANAGEMENT AND PERHAPS ONE OF THE MOST IMPORTANT THINGS THAT WE AS PATIENTS CAN DO, TO FACILITATE A SMOOTH POST-OPERATIVE RECOVERY IS TO HAVE A GOOD DISCUSSION BEFORE SURGERY ABOUT HOW POST-OPERATIVE PAIN IS GOING TO BE MANAGED.

IF YOU WISH TO WATCH THIS SHOW OWN AGAIN OR WATCH AN ARCHIVED VERSION OF PAST SHOWS PLEASE ABOUT TO ket.org/HEALTH.

IF YOU HAVE A QUESTION OR COMMENT ABOUT THIS OR OTHER SHOWS, WE CAN BE REACHED AT QY HEALTH@ket.org.

IF YOU WANT TO HAVE NO PAIN FOLLOWING SURGERY, GIVE Dr. GUM A CALL.

HE WILL BE HAPPY TO EXPLAIN IT TO YOU.

BE CAREFUL AND TALK TO EVERYONE ABOUT PAIN AND PAIN CONTROL.

ALL MEDICINES ARE NOT SAFE.

TALK TO YOU NEXT WEEK.

>> "KENTUCKY HEALTH" IS FUNDED IN PART BY A GRANT FROM THE FOUNDATION FOR A HEALTHY KENTUCKY.