Surgeons try in-the-wound drugs to ease pain

Monday, May 26th 2003, 12:00 am
By: News On 6

WASHINGTON (AP) _ The first time Kathy Kennedy gave birth via a Caesarean section, the wound was so painful she could barely hobble out of bed despite taking the powerful narcotic Percocet. But after her second C-section, ``I popped out of bed.''

The reason: a balloon-like gadget dripped a numbing drug below her stitches directly into the wound, without the grogginess and other body-wide effects of narcotics.

In-the-wound painkillers are a growing trend among surgeons trying out the technique for everything from heart bypass operations to knee replacement _ although just how well the $200-plus method really works isn't yet proven.

``It makes sense,'' says Dr. Michael Schurr of the University of Wisconsin, who is conducting what may be the strictest study yet of the method, in 80 hernia patients. ``The whole question is if the cost is worth the reduction in pain.''

But there is some promising early research: In a study of 35 heart-bypass patients to be published next month, Dr. Robert Dowling of Jewish Hospital in Louisville, Ky., found those who had the device drip a numbing drug onto their stitched-up breastbone left the hospital three days sooner than patients given a saltwater drip. A similar University of Tennessee comparison of 36 C-section patients found a 40 percent reduction in narcotic use.

In-the-wound painkillers are part of a bigger movement to improve a dismal problem: Up to 60 percent of post-surgery pain is undertreated.

Pain actually delays recovery. It stresses the immune system, and hinders movement _ a particular problem when optimal healing depends on quick physical therapy.

Worse, uncontrolled pain right after surgery increases a patient's risk of developing chronic pain problems months later, warns University of Wisconsin professor June Dahl, a well-known pain specialist. Somehow, acute pain sets up nerve pathways that leave patients vulnerable.

Narcotic painkillers are a mainstay, but they can cause their own problems, including grogginess and constipation, that can delay hospital discharge. Nor are they always enough.

A better approach is called ``multi-modal therapy,'' using an array of drugs that attack pain through different methods, thus decreasing narcotic use, Dahl says. But she recently studied 235 hospitals and found that new approach isn't used widely enough. In fact, a surprising quarter of hospitals still gave intramuscular pain injections, a slow-relief method not usually recommended.

Ask about the pain plan before your surgery, Dahl advises patients.

Top of her list:

_Using those popular new arthritis pills called cox-2 inhibitors, sold under such names as Vioxx and Bextra, before surgery can reduce pain-causing inflammation and decrease the amount of narcotics needed. Older anti-inflammatory pills, such as aspirin or ibuprofen, can't be taken before surgery because they can cause excess bleeding, a problem cox-2 inhibitors don't pose.

_Using nerve blocks and epidurals instead of systemic medication right after surgery also can decrease narcotic use.

But the trendier method _ one that also intrigues Dahl _ seems to be the ON-Q system, made by California-based I-Flow Corp., that drips painkillers directly into the wound. Competitor Stryker Corp. of Michigan makes a similar device called the PainPump. Both have been sold for several years, but are slowly gaining more surgeons' interest.

Any local anesthetic in the lidocaine family is put into a ball-like pump and drips down a tube into a tiny, hole-filled catheter stuck in the skin next to the surgical site. Tape the pump to the skin or wear it on a belt, and just pull out the catheter when the drug's gone a few days later.

Better study is needed to prove if systems like ON-Q decrease pain enough to justify their cost, stresses University of Utah pain specialist Arthur Lipman, calling studies so far equivocal.

Schurr's hernia study aims to do that. First he's checking for short-term benefit _ does ON-Q reduce pain and lower narcotic use? Then he'll track patients for a year, to see if reduced postoperative pain in turn lowers the risk of chronic pain that sometimes strikes after hernia repair.

``It's not pain-free surgery, it's reduced-pain,'' cautions Dr. John Moore, a plastic surgery professor at Thomas Jefferson University in Philadelphia who uses ON-Q during breast reconstruction for cancer patients and certain other big operations.

But patients like Kennedy, herself an obstetrics nurse in Centerville, Va., urge other patients to ask for it. ``I felt so much better. ... I wish more physicians did it on a routine basis.''