Every so often in science, particularly in medicine, there are “game-changers”—innovations that are so significant and monumental that their impact affects millions of people for the better. The major game changers can save lives. Examples might be the discovery of antibiotics, the invention of CAT scans and MRIs and the synthesis of antiviral medicines.
The minor game changers can be thought of as improving our lives—the development of midazolam as a safe and reliable pre-surgical sedative drug, the advent of propofol as a consistent and effective sleep-inducing agent for sedation and general anesthesia.
And now…a medication that falls somewhere between the major and minor game changers, Exparel (bupivacaine liposome injectable suspension). Why is Exparel so relevant and important today?
We’ve all seen the headlines about the ever-present and seemingly growing opiate and opioid epidemic that is killings thousands worldwide. In the US, a recent report by the IQVIA Institute for Human Data Science revealed these sobering facts:
- Patients across seven commonly performed surgeries were prescribed an average of 82 opioid pills to manage pain.
- Nearly 9% of surgical patients in 2017 became new persistent opioid users.
- Persistent opioid use has spiked among females, especially in women ages 18 to 34. Women are 40% more likely to become new persistent opioid users after surgery than men.
- Enough opioids were prescribed in 2017 to give every American 32 pills.
- Overdose deaths from opioids increased from 21,000 in 2010 to 50,000 in 2017. Nearly one-third of Americans say that they know someone addicted to opioids.
Enter the game-changer in pain management. Exparel is a newer medication whose application is unique and, in my opinion, much needed. It is an injectable liquid containing microscopic fat globules called liposomes, each containing quanta (or packets) of the well-known local anesthetic bupivacaine. Bupivacaine has been around for decades, and has been used by surgeons, anesthesiologists and pain doctors to relieve pain after all forms of surgery and to perform surgery and procedures under local anesthesia.
The people who make Exparel have figured out a way to administer bupivacaine in a safe and effective time-released formulation so that longer-term pain relief from surgical procedures can be accomplished. After it is injected by the surgeon or anesthesiologist, Exparel’s tiny liposomal (fat) globules dissolve gradually over many hours, even days, releasing the local anesthetic bupivacaine into the tissues. This means that, for many patients (and I have seen this first-hand), there appears to be little or no need for any narcotic medicine to be given or taken for many days following surgery. None! That means less exposure to the addiction-risking oral opioids, fewer side effects from opioids (the most common being respiratory depression, constipation, itching, urinary retention and hives) and fewer pain pills lying around that could be diverted (think teens, friends and thieves) for illicit use.
To me, this is clearly a game-changer. It’s perhaps not the magnitude of a penicillin-discovery game changer, but a significant one nonetheless.
Is Exparel perfect? No, no drug is perfect. Side effects, which are not frequent, include blurred vision, dizziness, nausea and constipation, among others. But generally, Exparel is very well tolerated. When used correctly, the chance of major or even complete pain relief in the first few days following surgery is quite high. It cannot be used for all surgeries, so your doctor needs to inform you if the procedure you’re having is amenable to Exparel therapy. However, I have personally seen what Exparel can do. It is truly amazing. A close friend from my anesthesia residency had a hip replacement last year and was injected with Exparel. The result? He was totally pain free for 72 hours after the surgery and did not need a single narcotic pill in that time.
That is what I call game-changing.
While I am clearly impressed by the benefits of this new pain-fighting agent, be mindful that not all surgical facilities will offer it, at least not yet.
If James Bond needed a Quantum of Solace in his 2008 action thriller, then you might consider a quantum of bupivacaine, in the form of Exparel, for your next surgery. And why not? Unlike Bond, there’s no reason to be tortured.