34 of whom had avoidable diagnoses. The most common avoidable diagno- sis reported was pain. This study also highlights the need for improved pain management immediately following outpatient surgical procedures to help prevent readmissions and resource use.

Preventing Opioid-Dependent Analgesia ASC-based clinicians understand that relying on opioids as the foundation for their pain management strategies can interfere with their goals to prevent neg- ative outcomes associated with their use, such as the increased risk for opioid- related adverse events (ORAEs). Fol- lowing use of opioids for pain manage- ment, more than 90 percent of patients report experiencing an ORAE, and more than 75 percent experience two or more ORAEs. ORAEs vary greatly in frequency and severity and can pose potentially serious complications that can interfere with the pathway to recov- ery. ORAEs may include nausea, pru- ritis, ileus, bowel obstruction, vomit- ing, confusion and dysphoria, as well as even more serious and life-threatening events, like respiratory depression or arrest. In addition, patients who experi- ence an ORAE versus those who do not have been reported to face a 68 percent higher readmission rate, 150 percent longer hospital stays, and 121 percent higher related medical costs, according to several studies.

How is Pain Management Evolving? As a surgeon performing knee and shoulder arthroscopy in the ambulatory setting, my goal is to provide patients with a high level of care through mul- timodal therapies, while minimiz- ing opioid use for pain management, and empowering them to follow this treatment plan to achieve an effi- cient recovery with fewer complica- tions. Perioperatively, the use of non- opioid treatment strategies has greatly improved the ability of surgeons to perform upper extremity surgeries in the ambulatory setting, instilling con-

Following use of opioids for pain management, more than 90 percent of patients report experiencing an ORAE, and more than 75 percent experience two or more ORAEs.”

—Scott A. Sigman, MD, Orthopedic Surgical Associates

fidence that patients will experience a satisfactory recovery with multimodal pain management strategies. Cur- rently, the postsurgical treatment pro- tocol for upper extremity procedures at our ASC consists of meloxicam 15 mg, prescription-strength acetaminophen 1,000 mg for five days, and gabapentin 300 mg for use at night for additional pain relief as well as a sleep aid. Addi- tionally, oxycodone (five pills only with no refills) is prescribed; however, I strongly encourage patients not to use this as first-line pain management. A major goal of ASCs is to prevent patients from experiencing negative outcomes, particularly related to post- surgical pain management. To com- bat this, many surgeons, like myself, try to clearly establish expectations of pain control with our patients prior to performing any surgical procedure. When I consult with my patients pre- operatively, we have an initial con- versation about the importance of minimizing exposure to opioids. This topic is addressed a second time immediately before surgery, and then again after surgery with patients and their caregivers, before patients leave the building to recover at home. I am often asked if dissuading patients from using opioids for recovery nega- tively impacts patients’ commitment to proceed with surgery at our cen- ter. On the contrary, patients often seek out these alternative treatment modalities because of their own con- cerns with the postsurgical use of opi- oids. A study published in PubMed in October 2017, “A Prospective Ran-

domized Study Analyzing Preopera- tive Opioid Counseling in Pain Man- agement After Carpal Tunnel Release Surgery,” showed that following car- pal tunnel release surgery, patients who received opioid counseling con- sumed significantly fewer pain pills over the course of the study compared with those who did not (1.40 vs 4.20 total pills, respectively).

While the use of multimodal treat- ment protocols in ASCs is ideal, newer nonopioid treatment options can incur additional costs. To ensure that more patients have access to nonopioid options and to help combat the growing opioid epidemic, the Centers for Medi- care & Medicaid Services (CMS) insti- tuted a ruling, effective January 1, 2019, that nonopioid postsurgical pain man- agement options—specifically liposo- mal bupivacaine—will be reimbursed for all Medicare patients undergoing surgery in an ASC. Considering this announcement, I am hopeful that com- mercial payers will adopt this forward thinking ruling and choose to cover lipo- somal bupivacaine as well as other non- opioid forms of peri- and postsurgical pain medications to help ASCs in their commitment to improve outcomes and reduce complications for the growing number of patients they serve.

Scott A. Sigman, MD, is a board-certified orthopedic surgeon at Orthopedic Surgical Associates of North Chelmsford, Massachu- setts. Write him at


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