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Exparel: Non-Opioid Pain Control in Women’s Health
Taylor Spurgeon-Hess • Updated Oct 28, 2024 • 40 hits
Exparel has emerged as a valuable tool in women’s health, offering a non-opioid solution for managing post-surgical pain in procedures like hysterectomies and C-sections. By delivering 72-hour pain relief, Exparel reduces the need for opioid prescriptions, addressing a critical concern in women’s health. Through precise injection techniques and integration into multimodal pain management strategies, Exparel has the potential to enhance the standard of care by providing safer and more effective postoperative pain control.
OBGYN Dr. Paula Bilica and gynecologic surgeon Dr. Steve McCarus explain the contemporary role of Exparel in their gynecologic procedures, covering its distinct advantages in women’s health and how to effectively administer it. This article features excerpts from the BackTable OBGYN Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable OBGYN Brief
• Exparel is a long-acting local anesthetic that delivers extended pain relief by gradually releasing bupivacaine over 72 hours, reducing the need for opioids.
• Originally used in colorectal and general surgeries, Exparel’s introduction to women’s health has helped to address the high opioid exposure associated with surgeries like hysterectomies and C-sections.
• Effective Exparel injection techniques involve the precise targeting of nerves, with infiltration both above and below the fascia for optimal pain control.
• Studies have shown a nearly 50% reduction in opioid use and reported pain intensity when Exparel is used in surgeries such as C-sections, significantly improving recovery.
Table of Contents
(1) Non-Opioid Pain Management with Exparel
(2) Bringing Exparel to the Field of Women’s Health
(3) Exparel Injection Techniques for Post-Op Pain Relief
Non-Opioid Pain Management with Exparel
Exparel is a long-acting local anesthetic that delivers sustained pain relief by slowly releasing bupivacaine, a commonly used analgesic, over an extended period of time. Unlike traditional bupivacaine, which provides short-term relief, Exparel's formulation can last up to 72 hours, making it a valuable tool for managing post-surgical pain without the need for opioids. This is particularly beneficial in major surgeries like hysterectomies and C-sections, where minimizing opioid use is crucial for reducing the risk of dependency and improving recovery. Administered through methods such as TAP blocks or soft tissue infiltration, Exparel offers a targeted, long-lasting pain solution that aligns with modern, multimodal pain management strategies.
[Dr. Paula Bilica]
As we know in the United States we do have an opioid epidemic. Anything we can do for our patients to provide any pain relief without having to give narcotics I believe is in our best interest. For a long time when I was training, we didn't have this and we would give 30 Percocet or whatever to patients after hysterectomies or C-sections. Especially not only in gynecology but obstetrics, it's really important because patients, if they're having a C-section and they need to take care of a baby, they need to take care of other children, having to take opioids is not ideal. I think it's really important. When I started utilizing this in my practice, it was a game changer for me to be able to offer this to my patients.
[Dr. Steve McCarus]
Yes. Amy, thanks for having us. It's a pleasure to be here with you as moderating this podcast. It is fun to share experiences among each other. I learn a lot from my colleagues and try to figure out what they do to enhance patient experience and outcomes. One of the biggest problems I always saw was managing post-op pain. Every patient is different, right? You all know that some women can have a hysterectomy and never take a pain pill. It's amazing. It always shocks me.
Then when you see some patients post-operatively really require a lot of analgesics, whether it's a minimally invasive hysterectomy or an open hysterectomy, or a C-section. I guess we haven't figured out how to do a minimally invasive cesarean section yet. I have a surgical practice. About seven years ago in the state of Florida, there was a big program through the state on reducing opioid exposure.
I do about 25 hysterectomies every month. I was a high opioid prescriber. I realized I needed to do something to address the issue. I got exposed to bupivacaine liposomal. Bupivacaine is what Exparel is. I really didn't understand much about it and didn't know how to use it. I reached out and tried to figure it out and saw that there was actually some good data around Exparel and other specialties, like in orthopedics, in hemorrhoidectomy, in bunionectomy. The original trials with Exparel, these Phase III trials, were pretty remarkable.
I've never had a bunionectomy or a hemorrhoidectomy, and I hope I never do. The reduction of opioid exposure and the recovery was pretty impressive. That was really early on before we had good data on cesarean. I'm sure Paula knows, and Amy, you probably know, there's really been some. Most of them came out of Texas, Paula, and Dallas. That C-section data was pretty impressive. Prior to that, there wasn't a whole lot of data around gynecology. I was prescribing a lot of opioids and realized I needed to do something to change.
I learned about Exparel, a unique formulation that gives a delayed delivery of bupivacaine into soft tissue. It's indicated for soft tissue of any type. It's also indicated for some of these-- Which I don't know much about, but some of these brachial plexus, shoulder surgeries, and other types of blocks in orthopedics. It's used a lot in orthopedics. We mobilized the team and tried to figure out if Exparel would be worthwhile. It was pretty expensive to use back then. It's gotten much better, and now there's a lot of contracting to allow us to use it more freely. It was indicated on any open search. Exploratory laparotomy, TAHs, open myomectomies.
Back then, I couldn't find an anesthesiologist that would do a TAP block, a transabdominous plane block. Paula, you probably had the same experience early on. There's been a really wonderful educational opportunity with anesthesia. Now anesthesia will do a TAP block. A TAP block is a regional block, as you all know. That really has been a huge huge help in cesarean section post-op pain management, as well as open hysterectomy and open myomectomy. It now has moved into these multimodal pain management protocols.
The American College of OBGYN, the ERAS Society, the American College of Oncology all endorse some type of mechanism to manage post-surgical pain other than opioids. It really has moved into a viable option. You can either do it through a TAP block that anesthesia does, either prior or after your procedure. Of course, with cesarean section, you can't do it until after the baby's delivered. They'll take liposomal bupivacaine and do a regional block, and it works wonderful.
Or you as the surgeon, and this is where I'd like to hear what you all do, but you can do soft tissue infiltration, where you do volume expansion. Expiril comes in a 20 mL valve. You have 20 mLs, and you can volume expand that with normal saline. Bupivacaine, or hydrochloride bupivacaine, or what we know as Marcaine, and maybe-- Paula, do you use Marcaine with yours?
[Dr. Paula Bilica]
I usually do the 20 of the Exparel, and then I do 30 of the Marcaine and 30 of saline. That gives me 80 cc's to work with, a volume. If I do a local infiltration myself, if my anesthesiologist, for some reason, is not able to do the TAP block.
[Dr. Steve McCarus]
What that is is that's called admixing, where you can mix hydrochloride bupivacaine, which is a fast-acting, short-duration analgesic. Every OBGYN has used Marcaine our whole careers, right? You take Marcaine, admix it with Exparel, 30 to 20, that's 50 cc's. Then you have the capability to volume expand that out to a total of 300 cc. You have plenty of Exparel to do soft tissue infiltration. One of my aha moments using Exparel, and I think we've all had those, on a left Bartholin's gland excision that I did, I hate that operation.
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Bringing Exparel to the Field of Women’s Health
Exparel was initially used in specialties like colorectal and general surgery, but its introduction into women’s health has addressed a critical gap in managing post-surgical pain. Women are disproportionately exposed to opioid prescriptions due to frequent surgeries related to reproductive health, such as hysterectomies or C-sections, making them more vulnerable to opioid dependency. By adopting Exparel, which provides long-lasting, non-opioid pain relief, women's health departments can reduce opioid exposure while improving patient recovery.
Some studies have highlighted Exparel’s ability to significantly reduce opioid use and pain intensity following surgeries like C-sections. One study showed nearly a 50% reduction in both opioid consumption and reported pain levels. This reduction in opioid dependence is especially valuable for new mothers, as Exparel’s minimal presence in breast milk (<1%) helps to allow a safer recovery while maintaining pain relief.
[Dr. Steve McCarus]
I think women's health gets the short end of the stick a lot because Exparel was used already in colorectal at my hospital and general surgery at my hospital. They were pushing back on the OBGYNs to use it. It really took a champion, somebody to speak up to pharmacy, because it comes out of the pharmacy's budget. Pharmacy, all they care about is their budget. We went to administration. We said, listen, women receive I think it was 65% of all opioid prescriptions in this country.
Think about women's exposure to surgery early in reproductive years. Somebody has an ovarian cyst or a miscarriage or an ectopic or whatever. They have surgery in their 20s and 40% of women are more likely to be persistent opioid users because of surgery, right? Surgery is painful and you've got to cover that. We really looked at women's health and looked at issues around surgery. I think it's one in every 15 people you operate on become chronic opioid users. There's 115 deaths every year in this country from opioid overdose. It's a gateway to other drugs.
There was all these issues around women's health. Women's health is important to the hospital because we all know women drive healthcare to what hospital you go to. If the mom says, oh, my son's sick, take her to that hospital. I had a great experience there. The exposure in women's health to opioids is pretty high. We were giving opioids and then if you think about it, how many opioids do you really need after a hysterectomy? 10, 15 or whatever it is. Maybe some patients don't use them at all and then they just have all these opioids hanging around the house.
When you talk to the pharmacy, he doesn't care about all. He just cares about his budget. We went to the nursing staff. We went to the administrators. At our OBGYN departmental meetings, we have to present the NOPAIN Act. They don't really understand it or know that it's happening. I think the real answer is having someone at the hospital who's a champion for women's health. Somebody who's going to look at the data, speak up. We're not going to overuse it, misuse it, we're going to use it. I don't use it if I do a laparoscopic oophorectomy. I don't use Exparel.
If you do a three-port stage four endocase, you do a four-port sacral colpopexy where there's a lot of twerking on the abdominal wall, there's a lot of surgical work that you're doing, I think it's indicated, right? The profile, there's never been a death that I know of from Exparel toxicity. If you look at the on-cue pump and the delivery of an analgesic in that arena, on-cue is another way to deliver an analgesic interabdominally. The plasma concentrations of the pivot cane are much higher than Exparel. Exparel peaks and comes down at 72 to 96 hours. You have to get, I think it's 2,000 picograms per mil of Exparel to see cardiac or central nervous system toxicity.
The profile is really low on side effects. You have a drug that's effective, it has a low toxicity score, it decreases opioid exposure in women's health, which is what we all really care about. Yes, it's much more expensive than bupivacaine hydrochloride. If you prevent one side effect of opioid and exposure or dependency, nausea, lightheadedness, rectal impaction because of narcotics, and low mobility and all the things that happen, so you can justify it. It really makes sense that it is an effective analgesic that's going to increase your patient's experience at the hospital, decrease their exposure to opioids. The cost is worth it. We have to justify risk-benefit of everything. I think that's how we approached it anyway.
[Dr. Paula Bilica]
We were the same way. We had a committee that got together and it was headed by the GYN oncologist. You also have decrease in hospital stay usually if you have less pain, less readmission rate, lower readmission rate, which is good for the hospital. Yes, the toxicity, as long as it's used appropriately and it's somebody who knows how to use it and how to admix it and they don't admix it, that with lidocaine, there are some rules about that. I've never had a toxicity from Exparel on any patient, I don't know of any colleagues that have. It's very safe.
…
[Dr. Steve McCarus]
ACOG put out a huge statement on that, opioid exposure to the post-obstetrical patient. They really recommended non-opioid intraoperative use and post-operative use, but they actually called out, I think, Exparel for a TAP block or soft tissue infiltration. That's probably been three years ago. ACOG really looked to trying to reduce-- All the opioid exposure in this country that we've heard about for the past, what, six years now, ACOG did put out a position statement on it, it really recommended it.
[Dr. Amy Park]
I don't know since I'm not really dialed into the labor suite at this point. They might have it or might not. I just think that it's such an opportunity. It's a big incision and there's a lot of manipulation going on there. It sounds like you guys are believers. I think that is a challenge for women's health, though, because you're right, colorectal and GYN-onc, these big incisions. Benign, OBGYN, surgery has the uptake and the attention to this issue has been for sure decreased and less attention compared to other fields.
This is where we learn from our colleagues and the interdisciplinary and multidisciplinary knowledge that gets shared. A woman has a colectomy or something else, hemorrhoidectomy, they get Exparel, and then women's health, we can't offer it. That's not right.
[Dr. Paula Bilica]
C-section is a major surgery, even though you're awake and it's a happy occasion, it is still abdominal surgery. I think that's why it was overlooked. Maybe they think, oh, she's having a baby. I don't know. A lot of people don't think of it as major surgery. It is. I tell my patients, you're having major surgery. This is a big surgery. You're having an abdominal incision. We have to go through all the layers, just like we do any of our surgeries. They have pain just like anybody else, if not more. C-sections are not a gentle surgery, and I tell my patients that, so I think even more so for them, it's important to have this pain relief.
…
[Dr. Steve McCarus]
In the way I think about it, any self-tissue infiltration, there's an application. I really like it for the vaginal cuff. Because if you think about tissue injury and the healing of tissue, it's visceral pain and somatic pain, right? Here's what I have found. There's no data on this. I don't know if it's reasonable. I think it is. Exparel will volume expand to 300 mLs. You don't dilute the ability of the liposomal bupivacaine to dilute. It doesn't dilute it. You get the effect.
Anesthesia will do a TAP block. They use 30 cc's on each side. They'll bring in an ultrasound machine. It'll scan the transverse muscle and the peritoneum. They'll do a guided infiltration, right? They'll use 30 cc's on the right side and 30 cc's on the left side. That's 60 cc's. If I do an open multiple myomectomy, which I do, I still have 240 cc's of Exparel that I can infiltrate. I'll let them do the TAP block. I'll do soft tissue infiltration of the abdominal wall.
Then what I do that I have found, I think it helps. There's no data on this. This is just anecdotal. I'll actually inject the uterus with Exparel where I've cut into the uterus and caused tissue injury and tissue trauma on a myomectomy. I'll do organ infiltration for visceral pain. Myomectomy, posterior repair, anterior repair. Back to my Bartholin's. I know we hate Bartholin's. I'm telling you, my aha moment with Exparel was a young girl that I did a left excision of a Bartholin's gland, which we all hate. We know it's painful. It's bloody. It's a terrible operation. I infiltrated the whole surgical field with Exparel. No kidding, zero post-op pain.
One of our urogynes here at this hospital had bilateral mastectomy and infiltrated Exparel. I know her well. I've known her for 25 years. She said, "Steve, I had zero post-op pain." Any soft tissue surgery, you can apply Exparel to that location. The thing is, it can't hurt and it only can help. Your chronic pelvic pain patients, 18% of endometriosis patients are treated with opioids that handle their pain. Now you've got to operate on that patient. You really have to set the stage with patient shared decision-making, if you will, that I'm not going to give you 30 Percocets. We're going to use a medication to do to reduce post-surgical pain.
Remember, the studies really show that there was, I think-- What was it? Paula, maybe you remember. I think it was 40 or 45% reduction of opioid consumption, reduction of pain with Exparel. The data is there. I think if you talk to your patient about what you're doing prior to the surgery, the whole goal we see in the C-section data, an Exparel TAP block C-section patient, the Foley's out, the IV's hep-locked, she's not getting IV Demerol or morphine or what have you. She's up. You can breastfeed. The plasma concentration of Exparel and breast milk is less than, what is it, Paula, 1%?
[Dr. Paula Bilica]
It's less than 1%. It's safe in breastfeeding. My patients love that as well. my hysterectomies go home the same day, which I'm sure yours do too, and it's really nice because they don't have any pain and they don't need to take their narcotics.
[Dr. Amy Park]
Yes, that's a great selling point for the patients who are ex-pregnant. I know that they don't even want to take ibuprofen or Tylenol. They are really concerned about what's coming in their breast milk and their suffering as a consequence. Pain is a cycle. You want to stop that pain before it gets started. We don't really know those pathways as well, like the acute to chronic pain, but as much as we can do to ease the patient experience is a good one.
[Dr. Paula Bilica]
Oh, yes, for sure. For sure. Like Dr. McCarus pointed out in C-section study, one of the studies, it was almost 50% reduction in opioid use and almost 50% in pain intensity. That's amazing.
Exparel Injection Techniques for Post-Op Pain Relief
Effective Exparel injection techniques involve precisely targeting the ilioinguinal, iliofemoral, and iliogenital nerves along the rectus abdominis to block pain at its source. To maximize pain relief, surgeons inject Exparel both below and above the fascia, ensuring thorough coverage. Unlike traditional bupivacaine, Exparel’s liposomal structure keeps it localized, so careful placement at 1-centimeter intervals is crucial. Surgeons often use a fan-like pattern, especially around incision corners and port sites, to cover the surgical area fully. This technique provides long-lasting pain control, helping patients avoid opioids for up to 72 hours postoperatively.
[Dr. Amy Park]
I remember hearing about Exparel from the colorectal surgeons doing combo cases, the hemorrhoidectomies. They were telling me that the patients would come in 72 hours, on the dot, when the Exparel would wear off because they were experiencing no pain. Then all of a sudden they were having routine post-op pain and they thought something was wrong, the sutures had broken down, or something like that. They are very facile with doing the fascia. That's the technique, right, is injecting it along the fascia or do you do it along the skin and the subcutaneous tissues?
[Dr. Steve McCarus]
You really want to block the ilioinguinal and iliofemoral and iliogenital nerves that run down the rectus abdominis, right? If you're doing a C-section or an open case and you're doing soft tissue infiltration. There's a couple of unique things about Exparel because it's encapsulated by a liposomal multivesicular envelope, right? The bupivacaine is encapsulated. Depending on where you inject it, the blood supply to that site, it'll break down that liposomal covering, and then the bupivacaine infiltrates into the tissue.
If you're doing soft tissue infiltration, you really want to do a good bathing of the fascia, below the fascia, above the fascia. You want to inject below and above the fascia to bathe the fascia completely. Every centimeter you do an injection. It's not like Marcaine. Marcaine, we put in the needle, aspirate, and infiltrate and it flows into the field. This is a different molecular weight and there's millions and millions of these encapsulated particles you're injecting. It has a tendency to stay where you put it. You want to be overzealous and really do a lot of infiltration below the fascia, above the fascia to hit those nerves.
The good thing is, how often do you all do an operation that a patient 72 hours out has moderate to severe pain? That's unusual, right?
[Dr. Paula Bilica]
No, not very often. I tell my patients, I say, this lasts up to 72 hours, sometimes longer. I've had patients 72 to 96 hours with all the Exparel. I'll tell them your peak pain is around 24, 48 hours, especially with a C-section and with my robotic hysterectomies. I said, so if we can get you that far out without narcotics controlling your pain, you're probably good. Maybe just a little Motrin if you need it, be a little sore at that point. You're right. You're not going to have any more severe pain.
I do the same thing you do when I do my C-sections. Like Dr. McCarus said, it stays where you put it. I do in a fan-like fashion at the corners, above and below the fascia. Then I'll go along above and below the fascia, across the incision, and then into the muscle and into the sub-Q a little bit with my extra left over.
[Dr. Amy Park]
We talked about it for open surgeries. It sounds like the TAHs, the C-section, the fan, and steels. Do you guys use it for slings or for laparoscopic surgery, robotic surgery for the incisions? Is there any utility in that?
[Dr. Paula Bilica]
Yes, absolutely. I use it on all my robotic hysterectomies and robotic surgeries. I'll infiltrate into the port sites around the fascia. Then we will place it along, just like we said, we put it where we want it. We try to inject and get those nerves that are going to cause the pain. Then some of my GYN oncologists that are at my hospital now are injecting into the vaginal cuff.
Podcast Contributors
Dr. Paula Bilica
Dr. Paula Bilica is an OBGYN in San Antonio, Texas.
Dr. Steven McCarus
Dr. Steven McCarus is a gynecologic surgeon in WInter Park, Florida.
Dr. Amy Park
Dr. Amy Park is the Section Head of Female Pelvic Medicine & Reconstructive Surgery at the Cleveland Clinic, and a co-host of the BackTable OBGYN Podcast.
Cite This Podcast
BackTable, LLC (Producer). (2024, October 15). Ep. 67 – Non-Opiod Pain Management in GYN Surgery [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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