Addiction Prevention: Nerve Blocks and Progressive Pain Management
David Lutton, MD discusses addiction prevention: nerve blocks and progressive pain management in orthopedics. He shares the parameters for Rx of opioids previously, what is different now and the latest information regarding best practices for the use of opioids. He talks about the ways to assess which patients might be more susceptible to developing opioid dependence and he highlights the multimodal pain relief approach as a way to allow patients to recuperate less painfully, more quickly.
Featuring:
David Lutton, MD
David Lutton, MD is a board-certified, fellowship-trained orthopaedic surgeon, specializing in shoulder, elbow, and sports injuries. A Northern Virginia native, he is a graduate of Thomas Jefferson High School for Science & Technology and the University of Virginia. He received a Master's degree in Anatomy, and attended The George Washington University School of Medicine & Health Sciences, where he graduated with Honors and was elected into the Alpha Omega Alpha (AOA) Medical Honor Society. He completed his Orthopaedic Surgery residency at GWU Medical Center.
Following residency, Dr. Lutton pursued specialty training at Mt. Sinai Hospital in Manhattan, NY, as the Shoulder & Elbow Fellow for the then president of the Shoulder & Elbow Surgery Society, Evan L. Flatow, M.D. There he received advanced, state-of-the-art training in minimally invasive, arthroscopic, and open techniques for treating all shoulder and elbow pathologies
Dr. Lutton remains very active in medical education at multiple levels. At Mt. Sinai Hospital in NY, the Orthopaedic Residents honored Dr. Lutton with the "2008-2009 Teacher of the Year Award." In 2009, 2010, 2011, and 2012, at the Annual American Academy of Orthopaedic Surgery Conventions, Dr. Lutton was an instructor to practicing orthopaedic surgeons in courses including "Reverse Total Shoulder Arthroplasty" and "Arthroscopic Rotator Cuff Tears." As Assistant Professor of Orthopaedic Surgery at GWU, he was honored by his residents with the "2010-2011 Teacher of the Year Award." He continues to teach at the GWU Medical School and the GWU Orthopaedic Residency Program. Dr. Lutton has many publications in peer-reviewed journal. In 2012 he was Co-Chair for the Mid-Atlantic Shoulder & Elbow Society Meeting held in Washington, DC.
Dr. Lutton continues his passion for education teaching courses on basic and complex shoulder and elbow reconstructive techniques to other attending surgeons on both a local and national level in cities such as Chicago, Naples (Florida), Philadelphia, New York City, San Diego, and Washington, DC, to name a few. He also volunteers his time as an editor for CORR and JSES.
In 2012, 2013, 2014, 2015, 2016 and 2017, Dr. Lutton was chosen as one of Washingtonian Magazine's "100 Top Doctors," nominated by physician peers.
Dr. Lutton's wife, also a Northern Virginia native, is a local primary care physician. In addition to taking care of his patients, he enjoys sports, fitness, and spending time with his wife and family.
Learn More About David Lutton, MD
Following residency, Dr. Lutton pursued specialty training at Mt. Sinai Hospital in Manhattan, NY, as the Shoulder & Elbow Fellow for the then president of the Shoulder & Elbow Surgery Society, Evan L. Flatow, M.D. There he received advanced, state-of-the-art training in minimally invasive, arthroscopic, and open techniques for treating all shoulder and elbow pathologies
Dr. Lutton remains very active in medical education at multiple levels. At Mt. Sinai Hospital in NY, the Orthopaedic Residents honored Dr. Lutton with the "2008-2009 Teacher of the Year Award." In 2009, 2010, 2011, and 2012, at the Annual American Academy of Orthopaedic Surgery Conventions, Dr. Lutton was an instructor to practicing orthopaedic surgeons in courses including "Reverse Total Shoulder Arthroplasty" and "Arthroscopic Rotator Cuff Tears." As Assistant Professor of Orthopaedic Surgery at GWU, he was honored by his residents with the "2010-2011 Teacher of the Year Award." He continues to teach at the GWU Medical School and the GWU Orthopaedic Residency Program. Dr. Lutton has many publications in peer-reviewed journal. In 2012 he was Co-Chair for the Mid-Atlantic Shoulder & Elbow Society Meeting held in Washington, DC.
Dr. Lutton continues his passion for education teaching courses on basic and complex shoulder and elbow reconstructive techniques to other attending surgeons on both a local and national level in cities such as Chicago, Naples (Florida), Philadelphia, New York City, San Diego, and Washington, DC, to name a few. He also volunteers his time as an editor for CORR and JSES.
In 2012, 2013, 2014, 2015, 2016 and 2017, Dr. Lutton was chosen as one of Washingtonian Magazine's "100 Top Doctors," nominated by physician peers.
Dr. Lutton's wife, also a Northern Virginia native, is a local primary care physician. In addition to taking care of his patients, he enjoys sports, fitness, and spending time with his wife and family.
Learn More About David Lutton, MD
Transcription:
Dr. Andrew Wilner (Host): Welcome to GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm your host, Dr. Andrew Wilner. I invite you to listen as we discuss addiction prevention and pain treatment. Specifically, we'll be discussing the role of nerve blocks and progressive pain management in orthopedics. Dr. David Lutton is a board-certified fellowship-trained orthopedic surgeon specializing in shoulder, elbow and sports injuries and assistant clinical professor in The George Washington University Department of Orthopedic Surgery and has a great deal of experience in treating complicated orthopedic cases where pain may be a prominent feature.
For orthopedic patients, the spectrum of pain control includes post-op pain because surgery has got to hurt, then pain control during the acute recovery followed by pain control during rehabilitation. Opioids have traditionally been used for pain control. But as we have well learned, they have significant and potentially fatal side effects.
Welcome, I'm looking forward to your views on this very challenging problem of pain control.
Dr. Lutton Does this alternative approach to anesthesia get in your way? I mean, from your point of view, I mean, of course you don't want your patients to have pain, but on the other hand, you don't want them to move around either while you're working. Is there any difference on your side of the operating table?
Dr. David Lutton: So I think that's a really good question. And it's actually one of the probably leading questions that other orthopedists ask me when they're trying to employ this kind of multimodal pain relief with a block or something like that. And I think the first thing that we need to do is we need to take a look at how it's treating our patients as the priority. And the reality is that I think providing this multimodal pain relief is really a critical part of the surgical experience. And so like comforting patients ahead of time that their pain is going to be well-controlled, it's not only going to lead to a better preoperative experience, but it can also lead to a much better postoperative experience.
So the second part of the question is addressing other physician's concerns about temporal interruption of their surgical day and will they be able to process through their surgeries in a standard way or in an efficient way. And really part of that really boils down to the pain service. And I will say, the GW Pain Service really streamlined the preoperative experience. So the patients are brought up probably a little bit earlier from admission to the pre-op area. And what that does is that allows the acute pain service to place the block before the surgery schedule. So ultimately, it doesn't affect my timing whatsoever. I do not need to add a single minute to my surgical day because of the multimodal pain relief and the preoperative blocks.
Dr. Andrew Wilner (Host): Well, that's fantastic. But it does sound like you must communicate, however, with the anesthesiologists. Is that right?
Dr. David Lutton: Yeah. There's no question, and it does take time to develop this relationship. A lot of this started kind of around when I started back at GW and, as I was a surgeon that had fewer patients when I was first starting my practice and a lot of it is just communication, which is integrally important for all of medicine, but even probably more so in both the surgical and anesthesia fields.
Dr. Andrew Wilner (Host): Is there a way to assess which patients are more susceptible to developing opioid dependence? In other words, would you avoid it in certain patients versus others? Can you tell that ahead of time?
Dr. David Lutton: . So that was actually directly evaluated and studied. There was an article out of the Journal of Arthroscopy that looked at predisposing risk factors to postoperative opioid dependence. And actually, this was directly in rotator cuff repairs. So this is kind of the most standard shoulder surgery that we do. And the number one risk factor for narcotics consumption after rotator cuff repairs was if a patient had filled an opioid prescription within three months of surgery, that was the number one. And then in decreasing order, there are certain psychiatric diagnoses that can predispose, patients with low back pain who require medications are predisposed. And then the last one that was found at least in that study is patients with global muscle pain, also known as myalgias.
Dr. Andrew Wilner (Host): Okay. So, really pretty quickly, you can establish whether a patient is at risk for opioid dependence from pain control after your surgery and take the proper action.
Dr. David Lutton: Certainly everyone is an individual and we want to evaluate each one as an individual, but certainly these give us potential early warning signs.
Dr. Andrew Wilner (Host): Some of these changes towards regional anesthesia and fewer narcotics and going home early were inspired by COVID. So now that you've developed them, and of course we're still in the midst of the pandemic, someday when the pandemic is over, are you still going to keep doing it this way?
Dr. David Lutton: Yeah, I would say that fortunately, at GW, we were actually ahead of the curve. A lot of these changes were done or at least instituted a decade ago. And we've benefited over time and throughout the pandemic from these changes that were immediately already available to us. What I would tell you has changed is patient expectation and patient fear. So when I have a patient comes in for surgery, their biggest barrier to discharge, their biggest barrier to going home is the fear of pain. And as COVID has taken over our country, what I have seen is the fear of COVID has usurped that fear of pain now that people are accepting this multimodal pain relief and these catheters and this regional anesthesia such that probably before COVID, we're doing the exact same thing that we're doing now, but probably 25% of my shoulder replacements were going home the day of surgery. But now, probably 70 to 75% of my shoulder replacements are going home the same day of surgery. And really the barrier is not pain, really the barrier is people having a social support at home. So it's changed patient's expectations.
Dr. Andrew Wilner (Host): One last question, if I may. Do you think that this multimodal pain control approach will eventually allow many orthopedic surgeries to be performed out of the hospital altogether, on an outpatient basis?
Dr. David Lutton: For sure. We're seeing that trend evolve over time. So yes, I think that it's allowing patients to recuperate less painfully, more quickly. The elderly can cognitively recuperate more quickly after anesthesia because they don't need all of the narcotics. So it just allows them to go home more quickly. And whether it is the same day or the day after surgery, either way we're making a very positive impact in their recovery and their ability to go home.
Dr. Andrew Wilner (Host): Dr. Lutton, thanks very much for this informative discussion. It's great to know there are proven techniques for pain control, which can avoid the dangers of narcotics.
That concludes this episode of GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. To refer your patient please call 1-888-4GW-DOCS. If you have a question for one of our specialists please email physicianrelations@gwu-
Disclaimer: Physicians are independent practitioners who are not employees or agents of The George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary.
There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.
Dr. Andrew Wilner (Host): Welcome to GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm your host, Dr. Andrew Wilner. I invite you to listen as we discuss addiction prevention and pain treatment. Specifically, we'll be discussing the role of nerve blocks and progressive pain management in orthopedics. Dr. David Lutton is a board-certified fellowship-trained orthopedic surgeon specializing in shoulder, elbow and sports injuries and assistant clinical professor in The George Washington University Department of Orthopedic Surgery and has a great deal of experience in treating complicated orthopedic cases where pain may be a prominent feature.
For orthopedic patients, the spectrum of pain control includes post-op pain because surgery has got to hurt, then pain control during the acute recovery followed by pain control during rehabilitation. Opioids have traditionally been used for pain control. But as we have well learned, they have significant and potentially fatal side effects.
Welcome, I'm looking forward to your views on this very challenging problem of pain control.
Dr. Lutton Does this alternative approach to anesthesia get in your way? I mean, from your point of view, I mean, of course you don't want your patients to have pain, but on the other hand, you don't want them to move around either while you're working. Is there any difference on your side of the operating table?
Dr. David Lutton: So I think that's a really good question. And it's actually one of the probably leading questions that other orthopedists ask me when they're trying to employ this kind of multimodal pain relief with a block or something like that. And I think the first thing that we need to do is we need to take a look at how it's treating our patients as the priority. And the reality is that I think providing this multimodal pain relief is really a critical part of the surgical experience. And so like comforting patients ahead of time that their pain is going to be well-controlled, it's not only going to lead to a better preoperative experience, but it can also lead to a much better postoperative experience.
So the second part of the question is addressing other physician's concerns about temporal interruption of their surgical day and will they be able to process through their surgeries in a standard way or in an efficient way. And really part of that really boils down to the pain service. And I will say, the GW Pain Service really streamlined the preoperative experience. So the patients are brought up probably a little bit earlier from admission to the pre-op area. And what that does is that allows the acute pain service to place the block before the surgery schedule. So ultimately, it doesn't affect my timing whatsoever. I do not need to add a single minute to my surgical day because of the multimodal pain relief and the preoperative blocks.
Dr. Andrew Wilner (Host): Well, that's fantastic. But it does sound like you must communicate, however, with the anesthesiologists. Is that right?
Dr. David Lutton: Yeah. There's no question, and it does take time to develop this relationship. A lot of this started kind of around when I started back at GW and, as I was a surgeon that had fewer patients when I was first starting my practice and a lot of it is just communication, which is integrally important for all of medicine, but even probably more so in both the surgical and anesthesia fields.
Dr. Andrew Wilner (Host): Is there a way to assess which patients are more susceptible to developing opioid dependence? In other words, would you avoid it in certain patients versus others? Can you tell that ahead of time?
Dr. David Lutton: . So that was actually directly evaluated and studied. There was an article out of the Journal of Arthroscopy that looked at predisposing risk factors to postoperative opioid dependence. And actually, this was directly in rotator cuff repairs. So this is kind of the most standard shoulder surgery that we do. And the number one risk factor for narcotics consumption after rotator cuff repairs was if a patient had filled an opioid prescription within three months of surgery, that was the number one. And then in decreasing order, there are certain psychiatric diagnoses that can predispose, patients with low back pain who require medications are predisposed. And then the last one that was found at least in that study is patients with global muscle pain, also known as myalgias.
Dr. Andrew Wilner (Host): Okay. So, really pretty quickly, you can establish whether a patient is at risk for opioid dependence from pain control after your surgery and take the proper action.
Dr. David Lutton: Certainly everyone is an individual and we want to evaluate each one as an individual, but certainly these give us potential early warning signs.
Dr. Andrew Wilner (Host): Some of these changes towards regional anesthesia and fewer narcotics and going home early were inspired by COVID. So now that you've developed them, and of course we're still in the midst of the pandemic, someday when the pandemic is over, are you still going to keep doing it this way?
Dr. David Lutton: Yeah, I would say that fortunately, at GW, we were actually ahead of the curve. A lot of these changes were done or at least instituted a decade ago. And we've benefited over time and throughout the pandemic from these changes that were immediately already available to us. What I would tell you has changed is patient expectation and patient fear. So when I have a patient comes in for surgery, their biggest barrier to discharge, their biggest barrier to going home is the fear of pain. And as COVID has taken over our country, what I have seen is the fear of COVID has usurped that fear of pain now that people are accepting this multimodal pain relief and these catheters and this regional anesthesia such that probably before COVID, we're doing the exact same thing that we're doing now, but probably 25% of my shoulder replacements were going home the day of surgery. But now, probably 70 to 75% of my shoulder replacements are going home the same day of surgery. And really the barrier is not pain, really the barrier is people having a social support at home. So it's changed patient's expectations.
Dr. Andrew Wilner (Host): One last question, if I may. Do you think that this multimodal pain control approach will eventually allow many orthopedic surgeries to be performed out of the hospital altogether, on an outpatient basis?
Dr. David Lutton: For sure. We're seeing that trend evolve over time. So yes, I think that it's allowing patients to recuperate less painfully, more quickly. The elderly can cognitively recuperate more quickly after anesthesia because they don't need all of the narcotics. So it just allows them to go home more quickly. And whether it is the same day or the day after surgery, either way we're making a very positive impact in their recovery and their ability to go home.
Dr. Andrew Wilner (Host): Dr. Lutton, thanks very much for this informative discussion. It's great to know there are proven techniques for pain control, which can avoid the dangers of narcotics.
That concludes this episode of GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. To refer your patient please call 1-888-4GW-DOCS. If you have a question for one of our specialists please email physicianrelations@gwu-
Disclaimer: Physicians are independent practitioners who are not employees or agents of The George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians. Individual results may vary.
There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you.