I mean, it's very interesting results. Yeah. So when the original study was done, it was in 2014, 2015, we were prescribing 50 tablets. Since those results came out, we reduced it to 30 tablets, and now after this analysis, we're doing, we're prescribing much lower amounts, like 10 to 15 tablets. We'll start on the left. Chris Strobing from Dartmouth. Thanks for a very nice study. Wanted to know if your state requires now a discussion with patients' risk assessment for opiate use in a separate consent form, because in New Hampshire, we now are required to do that, and it's I think made a significant impact on patients' buy-in on trying to reduce narcotics and being understanding of reducing the need and the excess prescriptions. And the other advantage that we have now is electronic prescribing, that now if somebody does need more, they don't have to drive two hours back to our hospital to pick up a written prescription. So is Connecticut doing the same? Right. Yes. So we also have an electronic prescribing option. So we actually mandated to prescribe all electronics using, or I'm sorry, all narcotics using our phones for the electronic prescriptions. So again, we don't need, our patients don't have to drive back to our offices to obtain these prescriptions if we need to prescribe more, which is why we feel comfortable giving them a lower amount, not having to worry that, you know, if it's the weekend or after hours, that we may not be able to get them more pain medications if necessary. And does the state have a mandate? No. So the state does not mandate us to have a consent form or a discussion that we need to sign. But based on our study, we typically now counsel our patients about the expectations and what they would need in terms of pain control after surgery. I'm quite shocked at your level of opioid prescription. I commented before, I work in New Zealand. In New Zealand, in Australasia, it would be extraordinary for a patient to go home with opioids. They go home with regular panadol, anti-inflammatories, and if they have, for example, buttock pain after sacral spine fixation, we give them gabapentin. Most of our patients complain about constipation as the main cause of discomfort after surgery. Of course, with opioids, you get an increased amount of constipation. So I think it's a cultural practice. It's like, how long do you pack a vagina after? You know, it's a habit. It's a habit to prescribe that. And I don't think it's a necessity. And I think your study has shown that. Yeah. It's really interesting. Thank you so much for your comment. We'll take one more question. Another great study. Your study, unlike Dr. Carter-Brooks' study, suggested that increasing age, there was more pain with increasing age, whereas there was less pain in your colleague's study. Could you comment on that? And did you control for type of surgery, or because vaginal hysterectomy had less pain? I wonder if there was a confounder showing that. Because anecdotally, older women require less pain medications. Yes. We were surprised by that as well. Our sample size is only 68. And we were not powered to examine, really, the effect of age on post-discharge narcotic use, which is why we are currently doing a prospective study so we can evaluate these relationships better. All right. Thank you very much. That concludes Session 5. All right. Now that Becky woke us all up, to dovetail on our scientific session from this morning, we have a wonderful panel planned for you. This is a multidisciplinary panel. As most of us know, the opioid crisis has reached levels we never could have imagined. And we are reminded daily of the devastation that this epidemic has caused our country, our communities, and some of us, our friends and family. As we are responsible for understanding and mitigating the potential for inducing opioid addiction in our patients, we are lucky to have a panel of renowned experts to educate us on this epidemic. Please welcome our moderator, Kevin Benson, who is an Associate Professor at Sanford Urogynecology, as well as our panelists. Danish Maslodust is a Pain Management Specialist at WellWord Regenerative Medicine and author of the book, 50 Shades of Pain, How to Cheat on Your Surgeon with a Drug-Free Affair. Alyssa Trowbridge is the Associate Professor at the University of Virginia. And Sandra Hilton is a Doctor of Physical Therapy at Entropy Physiotherapy and Wellness. Welcome, thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. 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Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Tha surgery handbook slash binder that the patients are given at our institution. It costs $5. And then there's the hydration before surgery, or what we otherwise called carbohydrate loading, also part of probably decreasing the inflammation, which prevents tissue catabolism and dehydration. And also, this decreases just the stress response and patient anxiety. Now, intraoperative, what happens then? I think it's so counterintuitive to everything we've ever learned. But actually, you really need to limit fluid that are given during surgery. So you have a fluid algorithm. And we're actually pretty strict with this. And in our institution, this is actually done with the PLEASE variability index monitor, which is almost like a pulse hop-off map. It's fairly expensive, but you can just also just continuously monitor blood pressure. And this is all to prevent fluid overload. Secondly, as part of what I'm so thankful for, Dr. Bruno's work, Dr. Ramathishan, Carter-Brooks, thank you so much for that research, again, contributing to the very limited data right now on the multimodal and analgesia as we try to minimize opioid use during surgery. So here's what should happen afterwards, ideally, also something we haven't been great at as surgeons, which is to get patients out of bed. I've been known to get many of my patients out of bed four hours after surgery. Why? Because it encourages bowel motility. It reduces postoperative, frustratory, and other complications. And also, it encourages the nurses and everyone on the team to remove tubes and drains and encourage walking. Again, back to normal, back to normal. Early feeding, they're fed the day of surgery, usually four or five hours after surgery. This stimulates intestinal motility, encourages hydration, and eliminates the need for further IV unnecessary fluids. So here are some of the outcomes we presented about two years ago, which should be online very soon. We prospectively looked at our patients before and after implementation of an enhanced recovery program at our Institution for Women Undergoing Pelvic Reconstructive Surgery. Our primary length of stay, I mean, primary outcome was length of stay. And I appreciated Vicky's comment, should this really be a major outcome? But it is right now. Secondary, we look at administration of opioids and pain scores. We also looked at complications, readmissions, and our patient satisfaction. So what do we do? Preoperatively, patients receive 20 ounces of Gatorade. And they finish drinking this just as they are parking in the parking lot. And then they receive Celebrex, Cavipetin, Acetaminosin, Escopolamine patch, and Oxaparin. And an IV is placed, but no fluids are given until they reach the operating room and are put to sleep. How are they put to sleep? Shown here, propofol, the ketamine, magnesium. And most importantly, absolutely no narcotics are given. And if any narcotics is to be given during surgery, it has to be with my approval or the surgeon's, as well as the anesthesiologist. There's also a lidocaine drip and a ketamine drip that's given. Obviously, that's tapered based on age. Lastly, the school-directed care. Post-operatively, what do we do for pain? Predominantly, we give midazolam and we give ketamine. Very, very rarely do we give opioids in the post-operative period. So what do we find? So we are a Nesquik site. I don't have time to talk about that today. Those were our controls before we started this in 2015. And our post-ERS group was 118 patients. You can see here, there essentially was no difference between the two groups, except we did have an increased number of robotic cases in the post-ERS group because of the addition of more robots at our institution, so more availability to do that procedure. So not surprisingly, as part of the protocol, we had a dramatic reduction in the number of morphine milliequivalents pre and post, as that was part. And also not significant, but the patients just actually received less post-op as well. Interestingly, absolutely no change in pain scores, meaning even though we gave a dramatic decrease in opioids, patients had no change in the pain scores pre and post. And very importantly, we got them out of bed, right? Because they weren't as drowsy. They weren't as tired. They weren't as dehydrated. They weren't as exhausted. They weren't as nauseated. So everyone was out of bed. As far as complications, this was a very, very big concern amongst our physicians at our institution. This was really going to lead to a lot of complications, dehydration, and so forth. And fortunately, that was not the case. We really saw no real differences in our complications before and afterwards. And this has been a little different than, for example, Dr. Carter-Brooks' series, where they did see differences before and after. So unfortunately, when we were doing our patient satisfaction scores, we were in between two different systems. We were having the hospital couldn't make up its mind about what to use. So unfortunately, I had limited data. However, I'll present something in a minute. But this was actually a big motivator of why our institution went to these protocols, was to improve patient satisfaction. And you can see here, big difference. Who would recommend our hospital? Also, this was my favorite. Percentage of people whose pain was always well-controlled. I think probably my most favorite, though, was here for the first time, we had a big change in patients' understanding of how they would take care of themselves after surgery. In other words, ownership of their care and their pain. And not surprisingly, when this ranking was compared to other peer institutions, ERAS ratings now at our institution were in the 70th percentile versus the 42nd prior to ERAS. Again, length of stay. Yes, that's what we're looking at. Not a big difference, right? We do minimally invasive surgery. So we went from 29.9 hours to 27. Probably not clinically significant. But I'll tell you what our hospital got excited about was this number. So 32% of our patients used to be discharged before noon. And now it went up to 60%. And I can tell you that's almost up to 90% now. Unfortunately, our readmission rates were quite low. So don't tell Linda, but the Purple Journal asked us to write a review. Shh, don't tell her. But so we went ahead and did that. And it couldn't be a full systematic review. It had to be an integrative review since there's very limited data on enhanced recovery programs. So what we were able to find was we found nine studies over the past decade. And the primary outcomes we were looking at in this review was, once again, length of stay, post-operative nausea and vomiting, pain management, and hospital cost. I obviously don't have time to go over all that data today. But the good news was that in this integrative review, what we found was that, once again, it supported implementation of enhanced recovery protocols. This is more generally in a benign gynecologic population. So we excluded all the GYN oncology studies. And it also, once again, decreased length of stay, improved pain scores, and reduced hospital costs without increased perioperative complications. So we have very limited data at this point. But this is what is available. So as we finished our analysis of our outcomes, I really was interested in, well, what's working? Again, not having had this framework that Dinesh has taught me, like, why do patients like this? Why is this working? Because it's such a dramatic change from what we've been doing. I mean, everything we were doing was exactly the opposite of what I had learned as a resident. So what we did is we went ahead and surveyed about 198 of our patients. And we used this HCAHPS survey. We had to modify it, obviously, as there is nothing really available to evaluate ERS protocols and why they're effective. So we were interested in the three phases of ERP interventions, preoperative, during their hospital stay, and after discharge. Fortunately, we got a pretty good response rate of 51%. And here's what they told us. 90% of them had a, their overall surgical experience was very favorable. And I figured there'd be some differences with regard to age, as Carter Brooks mentioned today. But there was not. There was no differences with regards to age when we looked at that, race, educational level, and their overall perception of their health or number of prior surgeries. Interestingly, 92% of patients reported that the preoperative teaching about surgery was very helpful. And we thought, oh, that's interesting. And specifically, it was this darn $5 binder that everyone really appreciated. They reported that this binder was very helpful. And actually, there was a very positive correlation of how these patient education components correlated to a more positive perception of their surgical experience. So here it is. If interested, this is available on our website. It's www.uvaeris. Very free. We taught a workshop. And the entire PDF is available. Please don't recreate the wheel. Change it as you will. But it's all there. And 90% of patients appreciate this. And in trying to put this in the framework that Dhanush was, because I couldn't understand why this. And I think what Dhanush has explained to me is that this was working on the brain. The patients knew what to expect, whether it was two hours before surgery, during surgery, after surgery, four hours after surgery, eight hours. They just knew. So apparently, this is like Ativan, a $5 Ativan. And lastly, how am I doing? We've been talking about a lot of science. And I figured I would make this very unscientific and share this letter with you all. It was a wonderful surprise I got from a patient about six weeks ago who felt very passionate about ERS. She had been a 59-year-old who had had stage 4 prolapse for 10 years. She's a PE teacher and just hadn't gotten around to taking care of her 10-centimeter prolapse. I recommended that we did a more, she was counseled and she preferred to have a native tissue repair, a TVH. Not surprisingly, she came back 18 months later with a recurrence. So it was interesting. She was actually a pre-ERS and then a post-ERS. And this is a letter she shared with me about six weeks ago. She didn't know I was doing this talk, but she said, I had an amazing experience following major surgery. I want to thank you for supporting and sharing this ERS program with me. I felt it was important to know what to expect before, during, and after surgery. The care team worked closely with me to plan my care and treatment. I followed the preparations for surgery as outlined in the notebook. The day of surgery, I drank the 20 ounces of Gatorade before arriving at the hospital. I believe the Gatorade helped me during the recovery because I didn't feel nauseated after surgery. Who knew? The patients are so smart. My pain level was zero, which took me by surprise. I felt mildly sore as if I had just done a ton of curl-ups. She's a PE teacher. What a great thing. When going to the short-stay unit, I was able to stand alone, walk from the recovery bed to my bed in the short-stay unit. Shortly afterwards, my capta was removed and I passed my urine test with flying colors. I slept very well. I give credit to the ERS protocol that aided in my surgery, recovery, and healing. Every patient undergoing surgery should have the experience of a quick and healthy recovery using the ERS protocol. Please share the great news. So yeah, and I will tell you, this is not an unusual experience. I would say this is a daily experience out of post-op checks. So again, in conclusion, there's a growing body of data to support the implementation of key components of enhanced recovery programs for benign gynecologic surgery. These outcomes are showing decreased length of stays, decreased opioid consumption, improved pain scores, and reduced hospital costs without increased perioperative complications. Thank you. Thank you. Thank you. Thank you. Thank you. Physical modality, it's the part that we can't treat with a pill. It's the part that we can't fix with surgery. And we have Dr. Hilton today here, who's a leading expert who's really gonna challenge some of the paradigms that we have for physical therapy. I know that some of the things we've talked about are just kind of mind-boggling to all of us as far as what we've thought and what we've accepted as true. So, Dr. Hilton, please enlighten us on some of the nuances and new thoughts on physical therapy. Thank you. I very much appreciate those beautiful presentations. And I just have a few. No conflicts to declare other than that I need to tell you I have a very strong bias towards reading the evidence and applying it into practice and de-adopting treatments that we might have spent an awful lot of time learning, but as more evidence comes out, show to be not of the value that we thought, which fits well with an opioid discussion. I do have a podcast where I talk about this more called Pain Science and Sensibility, and I have a practice here in Chicago. When we look at what we can do with physical therapy, talking about getting people up quickly after surgery, that's what we do in the acute care setting. We can certainly do that with people that are more in persistent pain as well and encourage them to understand they're in charge of their life and that it's okay to get moving. I think we have the strongest evidence saying that exercise and movement is going to be more helpful than most other things we can do to relieve pain. So what we do as a treatment philosophy is look at that whole person to identify whatever threats or concerns they have, to look at them as a whole person, not merely the piece that is hurting, and help them get a sense of self-efficacy in taking care of that pain response. And then we're aiming to create a solution to question whether or not it's safe to move. A lot of people with pelvic pain have been told, you know, don't sit. Sitting will cause problems. That can set up an awful lot. How do you work? How do you get to work? And people will start to self-limit their behavior to try and avoid something that they might have been told is dangerous. What we do in therapy is confound that expectation and make it not dangerous anymore so that they can safely sit, just as all of you are doing right now. And we look to restore that person to at or beyond their level of function. I think if we can get people feeling a little extra resilient, it will make them a little extra bold in pushing those barriers that pain can set up for us. What that looks like in treatment, fairly classic physical therapy for pelvic disorders. We do an internal vaginal and or rectal examination, assess the pelvic floor muscle function, tolerance, tone, strength, and endurance. We identify the tissues that are sensitive to touch because we're looking for those central sensitization, central pain mechanism influences in therapy where the tissue has become allodynic and what would normally be just touch is now protected or overprotected. We can identify any structures and physiology that is not working as it should and needs some specific rehab to it and then develop a program to address those tissues. And this follows really nicely on that program that we were just presented with of doing an assessment on that person because everyone that comes in is going to have a slightly different balance of what they need. And we can't really do it by just the interview alone or asking them what they think is wrong. We've got to do a good eval and try and find out how much of this person's dysfunction and suffering is due to any tissue problems, things that should be moving and aren't, tissue that might be a little stuck and need some help, weakness, fear. So we're looking also at their thoughts and beliefs and expectations and designing a program that is appropriately balanced so that we're addressing tissue problems and we're addressing thoughts and beliefs and expectations, blending in some of the interdisciplinary work we can use with acceptance and commitment therapy or cognitive behavioral therapy informed principles. And then as the patient changes or develops, we can adjust our treatment to have the right kind of balance. And it's not a unimodal form of care. It's certainly interdisciplinary and multimodal approach to education. To put that into perspective, I can give a brief patient system review, which was a 27-year-old female who would have 10 years of pelvic pain. So she started hurting when she was 17. It was progressively getting worse every year. Initially, she just couldn't wear underwear and had changed her clothes to have it not bother her. And when she got to me, she was mostly in a wheelchair. Pain was over the lower abdomen and suprapubic, the right labia and the clitoris is where it started. She'd been a little hypersensitive and prone to pain since childhood. She did not report any abuse and never had comfortable intercourse. She also never could tolerate a tampon and was very much not a fan of vaginal exams at the doctors. She anticipated that those would always hurt. She did get some tearing and bleeding with pain in the posterior vaginal wall. And as I said, she was not wearing pants. She was wearing a skirt. And in Chicago in the winter, that's a little drafty. So she was concerned about how she was going to be able to get along. Did the evaluation? No tolerance to touch at the perineum. It hurt. It hurt to even think about touching it. And that's a very big clue for me clinically. If I talk to someone and they say, my pain is increasing just thinking about you doing your assessment, then we know there are some central issues going on that are ramping up the pain response in this person. And it's not all about the tissues where they hurt. She couldn't sit on normal surfaces beyond 10 seconds. And walking was the classic that you'll see in the clinic with people with pelvic pain is they don't take very wide steps. And they will turn as a unit. They won't turn by taking a big step out to the side. Because that movement across the perineum can be too jarring. And it's just not tolerated. I use the pain catastrophizing score on every patient that comes in that hurts. Because I can break it down into three components that help me aim treatment. It breaks down into helplessness, magnification, and rumination. And there are very specific things that have been shown to be helpful for those thought processes. She asked me to see her twice a week. She had been going to clinics where she was being seen weekly for three hours a day and would have to recover every night from how painful that treatment was and then go back the next day and do other parts. And it was getting progressively worse. So when I saw her, she wasn't wearing any underwear. She had to lay down to come to the clinic. I did a sensory discrimination test on her. And essentially, all of the pelvic nerves were painful and allogenic. And her two-point discrimination and localization to touch was bad. Unable to sit or stand or walk with normal stride and very, very afraid. Her goal was to hurt less. And then she laughed and said, that's really no one's goal in life ever. I really want to take the bar. She had graduated first in her law school with pain. But she couldn't sit to take the bar. It's a two-day, eight-hour sitting test. She wanted to have a kid. And she wanted to be able to go back to running. So what we did was a multi-phased, multi-modal treatment of desensitizing the tissues. No painful treatment. Nothing that was going to make her cry, but definitely getting her to touch in ways that didn't hurt. And then we started re-educating and re-training thoughts and movements. Started her squatting and lunging. Started her back to strengthening. Got her doing things that were age-appropriate and interesting for her. Then we got her back to work-appropriate things. Pre-jump, pre-run, being able to sit long enough. And then the final phase of how we put this conceptually is what we call supported independence. I see her when she does something like yoga for five days in a row and ends up with a sore neck from practicing headstands. Or she goes rock climbing and sprains something. Her medications now are totally as needed. She no longer uses any topicals of anything. And she has a counselor she talks to. And now she says she used to have pelvic pain. So it's a classic exercise program that are moving and knowing that it's OK to move it and you're sore, but you're safe. Practicing pleasure is probably the biggest part. Pain's aversive. Pleasure is very rewarding. So she was told to do things up to six times a day that specifically felt good on purpose. And then the most important part of this is that this isn't anything I can do alone as a physical therapist. This was done with a very good physician, with a very good counselor, and with a lot of help and a patient who is very well motivated. I think together we can do some very interesting things. Thank you. Thank you, Dr. Hilden. At this point, we'll open it up to questions. And as we're waiting for questions, a couple of points for the speakers, I guess, if you can touch on it a little bit. Dinesh, could you talk to us that are now prescribing narcotics? What do you think is a healthy way to do that? We've been given a variety of regimens, a variety of products to use as a practicing pain physician to help us. What would you recommend? What do you think is the best way? I think it depends on the context of the situation. But for chronic pain patients, what I usually recommend when I see a patient is I don't believe in chronic daily opioid use. Because I think if you're doing a daily maintenance on opioids, you might as well not be taking it. All you're doing is you're increasing your pain responsiveness and amplitude of pain. So typically, what I recommend to my patients is our goal is to get you off of opioids. But if that's not a realistic solution, then at least get to a point where it's considered as rescue medicine, not maintenance medicine. So I'll write for like 10 pills a month for emergency use. But for the most part, we're working on other ways to address the pain. So with the ease of availability of post-operative narcotics through the automated systems, is there a role for us to more take a as-needed approach even from the beginning, as opposed to even a standard script for patients to go home with? Well, I certainly think that the ERAS protocols and the notion of preemptive analgesia is not dosing people with opioids. It's a matter of preventing that central sensitization and hypersensitivity that comes with a persistent pain or a traumatic pain like surgery. So if it's done right, the need for opioids is really minimal. My mom is, to me, a superhero.

opioids

medical practice

surgical procedures

minimizing opioid prescriptions

alternative pain management methods

enhanced recovery programs

multimodal approach

pain expectations