CODE speaking with Dr. Scott Sigman, MD at the 4th Interdisciplinary Conference on Orthopedic Value Based Care 2020

Session Topics:

  • Localized Treatment for Osteoarthritis Knee Pain with a Novel Intra-Articular Formulation
  • Opioid Sparing Orthopedic Surgery

Interviewee: 
Dr. Scott Sigman, MD
National Leader in Opioid
Sparing Orthopedic Surgery
Orthopedic Surgical Associates

Dr. Brian Cunningham:
We’re here at OVBC 2020 and we have the pleasure of talking to Dr. Sigman, one of the leading experts in opioid-free surgery and has a really great perspective on a number of advances in innovation. So thank you. Thank you for spending some time with us.

Dr. Scott Sigman, MD:
Oh, it’s my pleasure. Thanks for having me.

Dr. Brian Cunningham:
Tell us a little bit about your practice’s evolution towards opioid-free surgery. I think there’s a lot of interest nationally, but very few people have figured out how to do it well.

Dr. Scott Sigman, MD:
Yeah, I mean, it’s interesting. We all got caught up in this society of pain within our medical education and we just were told we’re going to use opioids, they’re not very addictive, they’re inexpensive, and that’s what we all got snookered into is the expression I like to say. It’s been a difficult time breaking that culture, which is really what we’ve been trying to do. I’ve been on this trail now for about seven years.

Dr. Brian Cunningham:
Okay.

Dr. Scott Sigman, MD:
We were one of the earliest adopters of liposomal bupivacaine in particular. Our hospital was very generous, the C-suite in particular. We were very hard hit with the opioid epidemic, and so they recognized that they were willing to spend money on the front side, which was the argument against opioid alternatives.

Dr. Brian Cunningham:
That’s right, that’s right.

Dr. Scott Sigman, MD:
And so we started using it in the inpatient setting and the results were so really quite profound that I then pushed it into the outpatient setting as well. I mean, the good news is when I first started giving these talks, we could barely fill a room and now it seems to be one of the most important topics that people are willing to listen to.

Dr. Brian Cunningham:
That’s right. There’s a waitlist now, yeah.

Dr. Scott Sigman, MD:
Yeah.

Dr. Brian Cunningham:
What were some of the big challenges both on the patient side and on the provider side, just specifically thinking there had to be a time when patients were like, “Whoa, no opioids? No pain medicine? I don’t know if I’m in for this.”

Dr. Scott Sigman, MD:
I think communication was always paramount and explaining to the patient that it’s not that we’re just not going to give you pain medication, it’s just that you’re not going to need it. When you have that conversation, what I found, in particular, is that just about every patient knows someone that has succumbed to the opioid crisis and epidemic, so even having the conversation with the patient was a relief that we’re going to address this for you, we’re going to take care of your pain, and we’re going to manage that for you, and we’re going to make sure you don’t need these opioids because they’re so addictive. As far as the paradigm shift for the provider, it’s not easy to change decades of process.

Dr. Brian Cunningham:
That’s right.

Dr. Scott Sigman, MD:
And so some doctors were early adopters and believers and many weren’t. There was the cost issue associated with opioid alternatives where the argument is yes, opioid alternatives are more expensive, but how expensive are opioids to our society as a whole?

Dr. Brian Cunningham:
That’s right.

Dr. Scott Sigman, MD:
Loss of life, the cost of managing substance use disorder, our firefighters and EMTs and Narcan and all of the loss of productivity at work.

Dr. Brian Cunningham:
Yeah, absolutely.

Dr. Scott Sigman, MD:
All of those things really play into the overall cost of the epidemic.

Dr. Brian Cunningham:
Yeah. Fascinating. Tell us a little bit even just an anecdotal or personal narrative, what were some of the struggles or some of the times when it didn’t go well in the beginning and then the evolution to get to where you guys have a protocol or a pathway now?

Dr. Scott Sigman, MD:
Yeah, that’s a great question. It took us about six months to get to the point where we knew the right mix, because in particular with liposomal bupivacaine, it’s really, it acts much more like a medical device than it does a pharma product.

Dr. Brian Cunningham:
Interesting.

Dr. Scott Sigman, MD:
In other words, you have to have the right volume and you have to be able to touch every nerve that’s been injured in the process of the surgical intervention.

Dr. Brian Cunningham:
Okay.

Dr. Scott Sigman, MD:
So even though you’re admixing, you’re not diluting, you’re just spreading the medication to more spots. And that took us a while. We were getting mixed results at first and it was a little disconcerting. My partner, Dr. Dave Prybyla, who’s an arthroplasty surgeon and I, we took the lead on this, and within six months we figured it out. It was actually quite gratifying because the ultimate study that was done to prove that liposomal bupivacaine does work basically was our mixture.

Dr. Brian Cunningham:
That’s awesome.

Dr. Scott Sigman, MD:
So it was very gratifying to know that we had a play into that, and now it’s awesome to be able to really help patients that I’ll never meet, convincing doctors that this is something we need to do for society. And the other thing that’s quite interesting, I say to the laggers, the doctors that are, “Well, maybe we’re going to do it. Maybe we won’t.” I say, “Look, the most liberating thing you can do in clinical practice is to become an opioid-sparing surgeon.” I said, “Before this, seven years ago, I was an orthopedic surgeon, but I was a pain management specialist.”

Dr. Brian Cunningham:
That’s right.

Dr. Scott Sigman, MD:
“I had to manage pain. I was writing refills and prescriptions. I was having to wean patients off. We had angry patients who were on the no medication list and all of these things, but now we don’t write refills.” As a matter of fact, for many patients, they don’t need opioids at all and so it’s liberating. It’s you don’t have that issue anymore. I can sleep well at night knowing that I’m not going to get calls at 3:00 in the morning from the emergency room from an irate patient.

Dr. Brian Cunningham:
I’m incredibly jealous already just talking about this, thinking through my inbox and my refill requests right now.

Dr. Scott Sigman, MD:
Yeah.

Dr. Brian Cunningham:
What are some new innovations or changes that are coming down the pipeline or that are already here that you have integrated into your practice or that you see has promise?

Dr. Scott Sigman, MD:
A great question. So there’s really two things that have been the most pivotal for me right now, I would say, within the last year and a half to two years. First is that liposomal bupivacaine became an on-label use for a regional block in the upper extremity.

Dr. Brian Cunningham:
Okay.

Dr. Scott Sigman, MD:
So what that has now transitioned, rotator cuff surgery, which was one of the most painful surgeries that you could undergo whereas many as even 10 to 12% of patients were on long-term opioids because of their surgery-

Dr. Brian Cunningham:
That’s right.

Dr. Scott Sigman, MD:
… are now opioid-free. They go through a two to a three-day window where they have minimal pain, don’t require opioids. It’s really completely transitioned rotator cuff as well as even total shoulder replacements now can be done as an outpatient.

Dr. Brian Cunningham:
Wow.

Dr. Scott Sigman, MD:
Really phenomenal, and the second is a newer technique called iovera, which is liquid nitrous oxide. And what we do is we actually freeze the cutaneous nerves.

Dr. Brian Cunningham:
Yeah, I’ve heard about this. Yeah, fascinating.

Dr. Scott Sigman, MD:
Yeah, so we do this about five to seven days before surgery. It’s the anterior femoral cutaneous nerve and the infrapatellar branch of the saphenous nerve and it’s remarkable. You do that block five to seven days in advance of surgery. We then do a liposomal bupivacaine, either doctor block or a localized block and patients are off all medication within five days for a total knee replacement.

Dr. Brian Cunningham:
That’s incredible. Is that coupled with an intraarticular injection as well?

Dr. Scott Sigman, MD:
Yeah, so we’ll do the intraarticular liposomal bupivacaine. It’s a field block that we’ll do. Vin Dasa down in New Orleans is a big proponent. Neer Evamine here in California, so we’ve validated this now and it’s really transitioned total knee replacement to a new paradigm as well.

Dr. Brian Cunningham:
Wow. Incredible.

Dr. Scott Sigman, MD:
Yeah.

Dr. Brian Cunningham:
Well, thank you so much for spending a little bit of time with us. Looking forward to your talk here this afternoon. Everybody tune in and consider the value based care conference next year.

Dr. Scott Sigman, MD:
#followthefro

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