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    Exparel controls postop pain

     

    A long-acting, intraoperative analgesic may be an adjunct to pain control in cosmetic surgeries.

    A study presented at this year’s annual meeting of the American Society of Aesthetic Plastic Surgeons evaluated the potential benefits of an extended-release formulation of bupivacaine liposome injectable suspension (Exparel, Pacira). Results demonstrated the analgesic may offer better pain control, reduce the need for opioids and ensure a more comfortable postsurgical experience.

    The current standard of care for pain management after surgery is based on intravenous and oral narcotics, which are highly sedative, delay ambulation and are associated with gastrointestinal, genitourinary and respiratory side effects that negatively impact patient satisfaction and recovery experience. We conducted a prospective study to assess whether a local nonopioid-based, long-acting analgesic could improve patient-reported pain and satisfaction outcomes.

    In the multisite study, 49 patients who underwent breast augmentation/reduction and/or abdominoplasty surgery were asked to rate their pain intensity and satisfaction with pain management, as well as report the number of opioids taken as rescue medication and the impact any associated opioid-related adverse events had on their quality of life.

    Investigators found that patients who received the drug reported low pain scores (mean score of ≤4.0 on pain intensity scale of 0-10), high satisfaction ratings (all patients reported ≥3.0 on a 0-4 scale) and took markedly fewer opioid pills than typically expected (mean of <3 tablets taken daily vs. historically expected 10 tablets per day in a typical postsurgical pain management paradigm).

    I have been using this method of pain relief routinely in most of my surgeries since its approval by the Food and Drug Administration in 2011. Before adopting this local analgesic method, our practice relied on opioids and elastomeric pain pumps to control postsurgical pain. Now we are able to deliver up to three days of pain relief without the need for catheters or pumps, and our opioid use has significantly decreased, with patients using about a third of the number if pills that they would without Exparel.

    In this formulation, bupivacaine is encased in multiple liposomes that break down over time to prolong its effect over 72 hours. Like traditional local anesthetics, liposomal bupivacaine is administered as a single-dose infiltration into the surgical site, and comes in a 20 mL (266 mg) single-use vial, and can be expanded in volume using up to 280 mL of preservative-free sterile normal saline.

    For abdominoplasty surgery, I typically add between 50 mL to 80 mL of injectable saline for a total volume of between 70 mL and 100 mL. I inject directly into the rectus sheath, along the intercostal nerves, around drains, if used, and along the incision site.

    In both the study and in my practice, liposomal bupivacaine worked very well in breast surgery, and in combination breast and body surgery. I am now extending its use to facial cosmetic surgery.

    The data presented here use some compelling patient-reported outcomes to make a strong case for shifting away from a traditional opioid-based postsurgical pain management regimen towards an opioid-sparing approach centered on Exparel.

    Stephan Finical, M.D., F.A.C.S., of Charlotte Plastic Surgery, Charlotte, N.C., was a study investigator and lead presenter.

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    • Anonymous
      Are you charging more for the use of this medication? It is quite expensive. The additional costs need to be accounted for somewhere. Are patients willing to add hundreds of dollars to the fees for this type of pain control? And should they be making that choice, or should we make it for them?
    • Anonymous
      In my experience, when given the option to minimize narcotics and achieve three days of pain control, patients are happy to spend less than one hundred dollars a day for Exparel. In the case of abdominoplasty, we've found Exparel to be so effective that we don't include it in the cost. Overall, it's a better, safer pain management option which improves my patients' recovery experience. As such, I strongly recommend it to patients during pre-op counseling, and most heed my advice. Stephan Finical, M.D.