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BackTable / OBGYN / Podcast / Transcript #67
Podcast Transcript: Non-Opiod Pain Management in GYN Surgery
with Dr. Paula Bilica and Dr. Steven McCarus
Everyone knows about the dangers of opioids, but how can physicians provide quality postoperative pain control without opioids? This episode of the BackTable OBGYN podcast, hosted by Dr. Amy Park, features a discussion with experts Dr. Steven McCarus and Dr. Paula Bilica on non-opioid pain control in obstetric and gynecologic surgery. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Exparel for Pain Management in Gynecologic Surgery
(2) Exparel Injection Techniques
(3) Exparel Clinical Pearls from Dr. McCarus
(4) Reimbursement for Soft Tissue Infiltration with Exparel
(5) Clinician Stories: Positive Outcomes with Exparel
(6) Utilizing Exparel in Women’s Health
(7) Tips for Obtaining Exparel at Your Hospital
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[Dr. Mark Hoffman]
Hello, everyone, and welcome to the BackTable OBGYN Podcast, your source for all things obstetrics and gynecology. You can find all previous episodes of our podcast on Spotify, Apple Podcasts, and on backtable.com.
[Dr. Amy Park]
This is Amy Park, and this is another episode of BackTable OBGYN. I am so pleased, so honored to have today as our guests, Steve McCarus. Steve is a board-certified and internationally-recognized OBGYN and chief of gynecologic surgery at Advent Health Winter Park. He's known for the development of the McCarus hysterectomy technique, and he specializes in treating complex gynecologic conditions like abnormal uterine bleeding, advanced endometriosis, infertility, menopausal symptoms, pelvic adhesions, prolapse, incontinence, interstitial cystitis, fibroids, and painful bladder syndrome.
[Dr. Paula Bilica]
He does it all.
[Dr. Steve McCarus]
Like everybody else.
[Dr. Paula Bilica]
He does it all.
[Dr. Amy Park]
I also have on our podcast Paula Bilica, who is a San Antonio OBGYN with Legacy Women's Health. She's striving to improve each of her patients' lives by providing world-class women's health care. She and Steve are here today because they are going to be talking to us about the non-opioid pain control with a focus on Exparel. I love talking about non-opioid pain control techniques. It, along with ARS, has totally revolutionized gynecologic surgery in my humble opinion.
I am so happy to hear what they have to say. I'm just going to hand it over to you guys and just ask you just in terms of why do we even need to be talking about this? Do we need Exparel in gynecologic surgery and OBGYN in general?
(1) Exparel for Pain Management in Gynecologic Surgery
[Dr. Paula Bilica]
Sure. 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.
[Dr. Paula Bilica]
Urgh. I hate those, yes. Those are not my favorite at all. I send them to my local-
[Dr. Steve McCarus]
Your urogynes.
[Dr. Paula Bilica]
-lovely urogynes.
[Dr. Amy Park]
That's so funny.
[Dr. Paula Bilica]
Or my GYN-oncs. After 20 years, I was like, I'm done.
[Dr. Amy Park]
I stopped doing those excisions. I just do marsupializations and a biopsy because they're so bloody. They are so deep. They have pain afterwards. It's not worth the dyspareunia. The risk of cancer is so low. It's just not worth it.
[Dr. Paula Bilica]
They're so not satisfying at all. A nice, myomectomy is satisfying. That is not satisfying.
(2) Exparel Injection Techniques
[Dr. Amy Park]
I was just going to say about what you described, Steve, is 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. I don't know if, Dr. McCarus, do you do that?
(3) Exparel Clinical Pearls from Dr. McCarus
[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.
(4) Reimbursement for Soft Tissue Infiltration with Exparel
[Dr. Amy Park]
That is amazing. Oh, I was just going to ask, in terms of reimbursement, does insurance cover the physician infiltrating the rectus and the soft tissue, because anesthesia can charge for the TAP block, right? Is that included in our global? Then how much is it for the Exparel?
[Dr. Steve McCarus]
I can tell you, Amy, it's been a real battle in that situation on trying to get Exparel in the past 10 years. You're exactly right. Anesthesia can bill for a TAP block where when we do soft tissue infiltration, it wasn't billable and it would be a cost to the procedure. That was an issue. We used Exparel when we thought we really needed it, right? We didn't overuse it or misuse it.
We wanted to be able to optimize the patient intraoperatively and postoperatively. Everybody has really good success stories with it. The nice thing is, and I'm sure you all have heard of that NOPAIN Act that is going to take in effect in, I think-
[Dr. Paula Bilica]
Next year.
[Dr. Steve McCarus]
-January '25, right?
[Dr. Paula Bilica]
January, right.
[Dr. Steve McCarus]
That's a huge breakthrough for patient exposure to Exparel. It was a bipartisan legislative bill that actually took a lot of hard work and a lot of education and a lot of conversations and a lot of interaction between pharma and people on Capitol Hill. It was unanimously passed and will go into effect in January of 2025. It was a preventable legislation that was aimed to really tackle this opioid crisis that we mentioned earlier. The good thing is now, I might be wrong on this, but I believe that hospitals have to make it available to patients and it can be a billable item. I think that's correct.
[Dr. Paula Bilica]
That's what I understand. It's in the HOPD setting and outpatient surgery setting, correct? That's where it's starting. Yes, it needs to be available. I know it's been a battle for some hospitals to get it. We had to fight for it at our hospital before, getting the anesthesiologist on board. Most of them are on board now, but this is going to be a huge step in the right direction because it's covering Medicare and Medicaid cases, then usually, private insurances will follow suit.
[Dr. Steve McCarus]
It's mandatory CMS reimbursement now in January 2025.
[Dr. Amy Park]
Yes, I was going to say, because my understanding is it's about $300, whereas probably a comparable lidocaine I'm guessing is, I don't know the exact cost, but it's 20 or 40 or something like that. Yes, so that's a huge win to get that covered. The thing that we cannot, let's say, put a price on is how many calls you get to your nurse triage or to the physician about post-op pain issues. Thankfully in gynecology, there's only five or seven things that people will call about, bleeding, pain, constipation, discharge. Thankfully, not very common to get an abscess or other things, but pain is a [crosstalk]
[Dr. Paula Bilica]
Fever.
[Dr. Amy Park]
Yes, fever, but the pain component is a huge component, especially for those patients who have pre-op pain, endometriosis, fibroids, they cause a lot of discomfort. That's priceless. Yes, it is.
[laughter]
[Dr. Paula Bilica]
It really is. For the patients, it's priceless because lidocaine compared to Exparel, there's no comparison. Like we said, there are some patients that can have surgery and walk out the door with no pain. That's rare. Majority of patients are going to require some sort of pain management. With the Exparel and being able to keep them pain-free for 72 hours makes a world of difference for the patient because the lidocaine doesn't last that long. We know that.
(5) Clinician Stories: Positive Outcomes with Exparel
[Dr. Amy Park]
Can you tell me how you arrived at your journey of being Exparel users? What about the patient experience? I think Steve shared his with the Bartholin's, the no pain after that. I think we all have these-- I remember for the laser, for instance, for Mona Lisa, I was like, oh God, this is so cheesy. Then I had this patient who had lichen sclerosus and we gave her topical clobetasol and it didn't work. Then it reactivated her herpes. I gave her tacrolimus and made her herpes worse.
We gave her a bunch of Valtrex, the Mona Lisa, then we just started doing it and it helped her. She got plasma cell vulvitis and then it just reversed all the changes. Then I became a believer. It sounds like the Bartholin's was the tipping point for Steve. How about for you, Paula? What did you think about it?
[Dr. Paula Bilica]
Initially at our hospital, the only surgeons that could get it were the GYN oncologists. They were using it, they started using it and I had talked to a couple of them and they really made it difficult for us to get it. We're the lowly OBGYNs. To do it for our C-section patients or hysterectomy patients. Finally, I was able to talk to admin and the GYN oncologists really believed in it because it was working so well for their patients. They jumped on board and helped us to allow us to get it on labor and delivery.
The first time I used it was on a C-section and I talked to the patient and I said, this is what it is. I explained to her what it is. I said, "I've heard great things about it. I've had some colleagues who've had great outcomes. What do you think?" She's like, "Let's do it." I had an anesthesiologist who was wonderful and who was all about the TAP blocks. He did the TAP block and I said, "Okay, I want you to let me know how you do and how you're feeling."
I went and rounded on her in the morning and she's a repeat C-section. She knows the difference between with and without Exparel. I went and rounded on her in the morning and she was up, she'd showered and I said, "How are you doing?" She says, "Oh my gosh, I feel amazing." She says, "This is so a 180 from my last surgery." She said, "Last C-section, they had to force me out of bed. I was in so much pain." She said she went home with narcotics and she really doesn't like the way she feels on it. Most people don't, and she was so happy. She said, "I don't need anything. I just need some Motrin. I'll take some Motrin home and I'm good." That really sold me on it.
Then I was able to get a team together at the hospital to get Exparel on board and started using it on all of my C-sections. Then I started using it on my GYN cases and I've had nothing but positive experiences with it.
[Dr. Amy Park]
In terms of your playbook, because I feel like that might be the roadblock is the administration portion. I think most physicians, we want our patients to not have a lot of pain. What were the compelling arguments to cover the cost? Because as of right now, 2024, it's not covered, but was it just the patient, the reduction in opioids?
[Dr. Paula Bilica]
That's one. You present them the data and you present them the studies. Then the other thing that, as we all know, hospitals are very interested in and very serious about are their patient satisfaction scores, right? When our GYN oncologist, presented, hey, look, these patients, they're very happy. They want to come back to this hospital for their next surgery and come back to us for the next C-section. Of course that got their attention, because that's very important to them. The Press Ganey scores, right? That's what they're called.
(6) Utilizing Exparel in Women’s Health
[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]
The other thing that just comes to mind is educating the nurses on the floor and having them know that this patient got Exparel and nurses in recovery because if there is a patient who's not responding appropriate to voice commands or she has CNS changes or cardiac changes, you want to know that patient got Exparel because anything could happen, right? Then on the floor, if you're admitting the patient, the nurses need to know this patient got Exparel. We're going to decrease narcotic use. Matter of fact, just give her Ofermev or Motrin or maybe Tramadol, something like that.
It really is a team approach in trying to optimize this patient experience and reduction to opioids. It seems to work. We transition from GYN only using it now to the OBs using it for C-sections. Everybody's on board and we're not hearing any really backlash on calls to that sort of thing.
[Dr. Paula Bilica]
Just going to piggyback on that with the nurses and it's a team effort. With all the hospitals, most hospitals now have ERAS protocols, and getting the Exparel to be part of that ERAS protocol. Like Dr. McCarus said, afterwards, most of my patients will just either get some Tordol or some Tylenol on top of their Exparel because anesthesia is taking care of them during surgery and then preoperatively they've gotten their ERAS medications. It is a team effort. As long as everybody's part of that, it really works well.
[Dr. Amy Park]
I was going to say that was something that I was curious about in terms of ERAS because I was talking to our MFMs here. This was now maybe two years ago, but they did not use ERAS on the labor suite. It seems to make sense that there would be a role for these-
[Dr. Paula Bilica]
For C-sections?
[Dr. Amy Park]
-wards. Yes, at C-sections at the time of C-sections. Are you guys using ERAS for C-sections?
[Dr. Paula Bilica]
Oh, yes, absolutely.
[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]
One thing that comes to mind just because we're talking about this, Exparel is contraindicated for a paracervical block. I don't think anybody would ever use it for that. You might say, well, why don't I knock out somebody's labor pains or whatever? It is contraindicated. It can only be used in obstetrics once the baby's delivered.
[Dr. Paula Bilica]
They'll do the TAP block after we deliver the baby. After we're done, then they'll come in. The anesthesiologist will come in and deal with the TAP block. Most of my anesthesiologists at our hospital are very receptive to it. We've had a few that we had to get on board. Once we tell them the outcomes of the patient, because a lot of times the anesthesiologist don't see the outcomes, they just do the TAP block and then they don't ever hear anything again. When they heard what the outcomes were and how well these patients did, they're like, okay, yes, we got it.
[Dr. Amy Park]
That's awesome. I have learned so much from all your tips and tricks. This is really the way to learn is from the experts and also not just the data, but hearing your anecdotal experience is always compelling. I really thank you guys for coming on the show and sharing your tips and tricks and also just how to get it on board, because a lot of people don't know how to get it. Getting a champion, getting your colleagues who can attest to its efficacy, talking to the pharmacy committee about it. Typically at hospitals, if you want to liaison with the pharmacy committee, what is the best method? It's going through your chair or your practice director. How did you guys know who to contact?
(7) Tips for Obtaining Exparel at Your Hospital
[Dr. Steve McCarus]
Mine was a little different because I was in the operating room and I wanted to use Exparel on a total abdominal hysterectomy patient. My GYN coordinator circulator said the pharmacy said you can't use. Which really ticked me off because I'm like, hey, who's he to say I can't use this medication? Then I then picked up the phone after the case and actually called him and asked for a meeting with him and went and talked to him. It was all about his budget. I just went right to pharmacy.
I think that was a little bold and maybe doesn't need to be the way to do it. I think what you can do at your OBGYN departmental meeting, I think a couple of things. What I'm planning to do at our next OBGYN departmental meeting is bring up the topic of the NOPAIN Act, so people just know about that because it's right around the corner where that will be applicable for our patients.
I would go to that OBGYN departmental meetings, say, hey, we need to talk about Exparel, there's good data on that now, and do it that way. Then the OBGYN department chair would then be able to talk to the pharmacy and the leadership team to get something together, maybe bring the pharmacy director to your next OBGYN departmental meeting and have a discussion around Exparel. That's probably the way to do it.
[Dr. Amy Park]
Okay, because I was going to say also every resident in this country and fellow have to engage in QI projects, so quality improvement. This is an opportunity to do that work, publish your outcomes on it, follow the outcomes. There's lots of mechanisms. It just takes one or two very motivated folks to discuss the data because it sounds very compelling.
[Dr. Paula Bilica]
That's how we did ours. We got a committee together and went through our OBGYN meeting, division meeting, and went through this chair. Like I said, we had the GYN oncologist on our side, so that was very helpful.
[Dr. Amy Park]
It is weird when they have it on formulary and then you can't access it because we're not a certain service line. I would definitely get some riled up over that.
[laughter]
[Dr. Paula Bilica]
Oh, for sure. Hey, they do that with IV Tylenol. At our hospital, they're very strict with that. It's like TXA, they were like that for a while with that as well.
[Dr. Amy Park]
I applaud you guys for doing the work and for advocating for better pain control for our patients because women deserve pain control too, obviously.
[Dr. Paula Bilica]
Absolutely.
[Dr. Amy Park]
I appreciate Steve and Paula coming on the podcast and then these guys are going to the major meetings. Is there a good way to contact you guys if people have questions like LinkedIn or Twitter or something?
[Dr. Steve McCarus]
Yes, I'm on LinkedIn or they can email me directly, no problem, but I'm on LinkedIn for sure.
[Dr. Amy Park]
Okay, perfect.
[Dr. Paula Bilica]
Yes, I'm on LinkedIn. I'm on all the other social media platforms as well.
[Dr. Steve McCarus]
Amy, we actually are doing a program in Vegas in October where we're having a hands-on workshop learning how to administer Exparel. It's on LinkedIn, so maybe if anybody's really interested, and it's a free program, so if anybody's interested, we'll see them in Vegas.
[Dr. Amy Park]
Awesome.
[Dr. Paula Bilica]
Fun.
[Dr. Amy Park]
Perfect. All right.
[Dr. Paula Bilica]
Thank you so much for having us.
[Dr. Mark Hoffman]
Thank you so much for listening. If you haven't already, make sure to follow the podcast, rate it five stars, and share with a friend. If you have any questions or comments, direct message us at _BackTable OBGYN on Instagram, Twitter, or LinkedIn.
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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