and required fewer opioids than those who didn't receive Exparel.
With Medicare now reimbursing for Exparel in ambulatory surgical
centers, many expect a surge in the drug's usage. Exparel could soon
face competition from other long-lasting local analgesics.
"Yes, Exparel is the only commercial drug out there right now, but
there are a number of drugs in various stages of testing," says Dr.
Elkassabany. "I'm confident that in 5 or 10 years from now, you'll have
multiple drugs on the market."
3. New uses for old drugs
Thanks to the opioid crisis, the phrase multimodal pain manage-
ment has become as ubiquitous in the world of orthopedics as same-
day total joints. But unlike the latter, effective multimodal pain man-
agement is something virtually any facility can do.
"What we're seeing with multimodal is old drugs getting new uses,"
says Dr. Elkassabany. Take ketamine, an NMDA receptor antagonist
that's been around for decades, but is just recently being used to
reduce opioid usage after surgery.
"With the appropriate patient and the appropriate procedure, vast
evidence supports ketamine as a very beneficial drug for multimodal
pain management," says Dr. Elkassabany.
Lidocaine and the sedative Precedex (dexmedetomidine) are exam-
ples of older drugs that, when added to a multimodal regimen, could
reduce the need for opioids during or after orthopedic procedures.
An effective cocktail of multimodal analgesia tends to be a small
dosage of gabapentin and some PO Tylenol, says Dr. Hickman. Of
course, multimodal is a means of reducing opioids, not limiting them
altogether. "Along with gabapentin and celecoxib, our outpatient total
joints patients do get a narcotic, usually hydrocodone, but it's only to
be used as a last resort," says Dr. Hickman.
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