Father-Son Surgeons Fight Opioid Crisis Via Portland Practice

PORTLAND, OR — While debates go on across the nation on how best to curb the opioid crisis currently causing the deaths of 115 Americans every day, a father and son surgery practice in Portland has moved forward with its own solutions — one of which includes the use of Exparel, a non-narcotic alternative to using opioids for pain relief following surgery.

Doctors Jay and Michael Malmquist run Malmquist Oral & Maxillofacial Surgery at 1750 S.W. Harbor Way in downtown Portland, and since 2015 have made use of Exparel to help reduce the number of opioids they prescribe to their surgical patients.

"We're trying to be at the forefront of the opioid crisis," Michael told Patch. "Surgeons as a whole are contributing (to excessive opioid use and addiction) … and I think it's our job to minimize the need for post-op narcotics."

While Michael firmly believes in the Exparel product and mission, he also says the opioid epidemic can be further addressed by doctors and surgeons who take better post-op responsibility for the care of their patients and do more to personally ensure their recoveries are monitored and managed appropriately — and his father, Jay, agrees.

Prescribing narcotics is one way for doctors and surgeons to avoid taking post-operative calls at night and on the weekends, Jay said. Casually prescribing opioids because it's quicker and easier may save time for the practitioner and money for the patient, but the longterm result can be damning.

Of the 99 percent of surgical patients who are prescribed opioid medications for pain relief, roughly 14 percent will become addicted to those medications after just one week of consumption, Michael said.

And, according to a 2016 statistic from the Center for Disease Control, 460,000 new opioid addicts are created every year in the United States through haphazard narcotic prescriptions like those described by Jay.

Because they do still prescribe opioids on occasion, both Jay and Michael clarified they've significantly reduced the numbers of pills assigned to those prescriptions.

While Michael would formerly prescribe 20 narcotic pills on average following a surgery, he has lowered that number to between eight and 12 pills on average since he was introduced to Exparel at a conference in Dallas, Texas.

"We have dramatically reduced the numbers of opioids since the use of Exparel … from 20 to 10 Percocet tablets for a third molar procedure, or even reducing the drug type to a Class III narcotic," Jay confirmed. "It is a fantastic alternative and meets the national call by everyone from the President down to local state boards to adjust the use of narcotics.

"Personally, I have been very careful to control the use of these drugs by writing low number scripts, trying alternatives, such as NSAIDS (non-steroidal anti-inflammatory drugs), and providing long term local anesthesia, such as the use of Marcaine," he continued.

However, Exparel isn't so roundly lauded by the medical industry. The price and duration of relief for Exparel, for example, has been a matter of controversy for at least three years.

Studies conducted in 2015 reportedly found no demonstrable benefit to using Exparel over a similar, albeit older and less expensive product called bupivacaine.

“We’re not saying Exparel didn’t help the patient, and it appears to be a safe drug to use,” Dr. Rajesh Jain told StatNews.com in December 2015. “The big issue is if it’s worth the cost. We didn’t find it to be any more effective, so there’s no reason to spend more on an expensive drug.”

Jain, an orthopedic surgeon at Virtua Health System in Voorhees, N.J., co-authored a review on the efficacy of two different methods for injecting bupivacaine medications. He ultimately concluded that patients did not note a difference in their levels of pain based on either of two bupivacaine injection methods.

Michael, though not specifically referring to Jain's study, did say a lack of expertise by surgeons who perform procedures for which they're not specialized can contribute to the overall pain experienced by a post-surgery patient, noting an observed increase in the desire for opioids by patients who simply want to reduce their pain as quickly as possible.

"If a patient is having that much pain I want to see them … because that means there's a problem," Michael said.

Whether Jain's study was conducted with surgeons who were intimately familiar with how to properly administer Exparel is unclear. But with a price difference of nearly $200 for Exparel versus the older products, both Jain's and Michael's points are worth considering.

"The issue that has become significantly important is the hospital’s lack of use of Exparel. We have tried to lobby the hospital but their decisions are based on costs and not what is best for the patient," Jay said. "They would rather use a narcotic pain pump over Exparel even though it will functionally eliminate the narcotic use when the Exparel is used properly. Very sad scenario and one that is not likely to change without significant force by the media and the companies."

Michael described another example of the problem he sees in a lack of awareness.

During a conference/study club lecture, Michael said he asked 20 dentists and various specialists if they knew about Exparel; none did, and as far as he's aware, only his and his father's practice is using Exparel in Portland.

One surgeon in Olympia, Washington, has begun using Exparel since Michael told him about it, he said, but he's not aware of any widespread use across the Pacific Northwest.

Another problem is that most insurance companies don't cover Exparel, Michael said.

"The skeptical patient is generally concerned about the additional cost and not the pain relieving process. They trust the doctor almost always to do what is right," Jay said. "The pricing power is the main consideration. Folding the cost into the procedure costs is a consideration. The patient will believe if educated properly by staff, the doctor and the media.

"Think of the power of advertising the prescription drugs for heart disease, anticoagulation or even certain antibiotics," he continued. "This process must be one of education to the doctor and the patient. Rarely does the patient question the doctor’s choice of medication once explained. To be skeptical of the drug is to not understand the drug or not trust the doctor’s judgement. Bottom line: education is key."

Images via Michael Malmquist