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'Kill the pill': Wisconsin surgeon on a mission to reduce patient opioid use with targeted freeze therapy

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Posted at 8:26 AM, Oct 29, 2021

MANITOWOC (NBC 26) — A Northeast Wisconsin surgeon has made it his goal to minimize patients' exposure to opioids as overdose deaths increase significantly during the COVID-19 pandemic.

Dr. Robert Limoni, an orthopedic surgeon at Holy Family Memorial in Manitowoc, began using Iovera treatment about five years ago prior to knee replacement surgery. Iovera is a type of cryoanalgesia treatment. Limoni uses it to target the nerve where the impulse of pain runs through the knee. He said the device can block pain signals without impacting muscles so patients don't lose strength in the leg.

"What they're doing is they're placing basically an ice cube next to the nerve, which stuns it and freezes it," Limoni said. "Generally it provides pain relief for about three months."

Iovera is FDA-approved for treatment prior to knee replacement surgery. Limoni said the treatment is performed one to three weeks before surgery.

Since using this freeze therapy technique, Limoni said he's seen patients need fewer narcotics after knee replacement surgery. He said patients also rehab quicker.

That was the case for John Chandik, Green Bay. Limoni performed knee replacement surgery on Chandik over one year ago.

Chandik said he heard the pain after this surgery could be "intense," especially during rehab. At Limoni's recommendation, Chandik opted to try Iovera therapy. Chandik said he received the treatment about a week before his surgery. While he recalled using a pain relief drug after surgery, Chandik said Iovera therapy aided in his recovery.

“The pain was nowhere near what I was told by other people in terms of the pain for the recovery process," Chandik said. “To my knowledge at least, it’s extremely effective. Obviously avoiding opiates is, in today’s medical knowledge, a better thing to do. This was accomplished through the use of the pre-injection material.”

Limoni said this is the goal of Iovera therapy.

"As we know there's an opiate crisis in the United States and there are some studies that would say up to 15 percent of people who go through a knee replacement surgery develop some tolerance to pain pills after surgery," Limoni said. "Our first goal is to kill the pill. We don't want people to be taking a lot of pills after the surgery."

Opioid-related deaths increased 34% from 2019 to 2020 in Wisconsin, according to the Department of Health Services. Data shows 1,227 people died from an opioid overdose in 2020. This year, there were 257 opioid recorded deaths through March 31.

DHS data shows 16 people in Manitowoc County died from an opioid overdose in 2020, four more than the year prior.

"We've always struggled with pain management and surgery. It's always been an issue," said Dr. Vinod Dasa, vice chair and director of research for the Department of Orthopedics at LSU Health and a fellow with the American Academy of Orthopedic Surgeons. "Then obviously we have the opioid epidemic. So I'd probably say over the last five to six years, there's been a lot of interest in figuring our sliver of healthcare how can we better manage pain around surgery."

Dasa said he began using Iovera therapy on patients in early 2014. He found the best way to use the technique was right before knee replacement surgery, similar to Limoni.
After talking with physical therapists, Dasa learned patient recovery time after surgery was cut by 75%. Dasa said he pulled prescription data to see if the number of opiates he prescribed after surgery decreased: He found narcotic prescriptions dropped 45% within the first three months of surgery.

Dasa said he went "cold turkey" and stopped prescribing opiates after surgery in May of last year. His research team looked at the first 40 patients after doing that and found 32 of them didn't have any opiates going into surgery. Of those patients that were opiate-naive, Dasa said 85% were opiate-free after surgery and only needed Tylenol and anti-inflammatory drugs.

"We never thought this was possible 10, 15 years ago," Dasa said. "We were prescribing opiates like it was candy for our knee replacement patients, because it was one of the most painful procedures. So when you go from prescribing this like it was nothing to zero, it's a pretty remarkable change. Almost a 180, which is hard to find in healthcare and medicine."

Based on his clinical trials and published research, Dasa said negative effects of Iovera therapy include bruising and swelling around the treated area. Dasa said he hasn't seen permanent nerve damage, infection or hematomas.

Limoni reported similar results. He's hopeful to reach a "narcotic-free total knee" within the next 10 years.

"Iovera has probably been one of the greatest steps forward in reaching that in my career," he said.