Episode 31: Orthopedics Without Opioids

Change often takes bravery and time, especially in medicine. In this episode, Dr. Scott Sigman chronicles his uphill battle of proving to the orthopedic world that it is possible to practice surgery without prescribing opioids. In doing so, he has not only paved the way for innovation in his field, he has also demonstrated the potential to save patients from this dangerous epidemic.

Engage With Us

How to listen: shows.pippa.io/paradigm-shift-of-healthcare/howto

Archive of previous episodes: https://www.healthconnectivetech.com/paradigm-shift-of-healthcare/

Follow on Twitter: twitter.com/p3inbound

Full Transcript

Announcer: It’s time to think differently about health care. But how do we keep up? The days of yesterday’s medicine are long gone and we’re left trying to figure out where to go from here. With all the talk about politics and technology, it can be easy to forget that health care is still all about humans and many of those humans have unbelievable stories to tell. Here we leave the policy debates to the other guys and focus instead on the people and ideas that are changing the way we address our health. It’s time to navigate the new landscape of health care together and here’s some amazing stories along the way. Ready for a breath of fresh air? It’s time for your paradigm shift.

Michael: Welcome to “The Paradigm Shift of Healthcare” and thank you for listening. I’m Michael Roberts with my co-host Scott Zeitzer. On today’s episode, we’re talking to Dr. Scott Sigman, an opioid-sparing orthopedic surgeon who’s the founder and Chief Medical Officer of OrthoLazer. Dr. Sigman, thank you so much for coming on the show today.

Dr. Sigman: Oh, it’s my pleasure. Thanks for having me, Michael, appreciate it.

Michael: Certainly.

Scott: You know, I want to jump in really quickly, Dr. Sigman. We met in person at OSET, what is Orthopedic Surgery and Emerging Technologies Conference, out in Las Vegas in December. And frankly, I just think you’re an impressive guy with, you know, with a really interesting background. One of the things that, when I was talking to you, we were talking about a lot of different things. It started with OrthoLazer and your laser treatments but really my first thing that I really was surprised about was like, “Wow, you really do get into a lot of different techniques to solve unique problems.”

Dr. Sigman: Yeah, that’s absolutely correct, Scott. So, first and foremost guys, you gotta let me introduce myself, it’s my shtick, my…

Scott: Go for it. Absolutely.

Dr. Sigman: Okay, good. So, I like to describe myself as the original opioid-sparing orthopedic surgeon, healer of knees and shoulders left and right, social-media influencer #followthefro. So, there you have it.

Scott: Yes. And that hashtag, #followthefro, everybody, it is good. If you’re interested in orthopedic surgery and some really fun and interesting thoughts about subjects overall, #followthefro is…I wholly support that, if you want to follow that.

Dr. Sigman: Yeah, I really appreciate it. So yeah, you know, it’s so funny. I mean innovation, in general, within medicine is a real struggle. Doctors like to stay on the path in which they’ve learned. They don’t like to get outside of their comfort zone. You know, learning a new operation is not typically an easy thing to do. You’re in the sweet spot, you’re doing what you normally do, and now somebody says, “Well, you know, there’s this new technique that you need to do.” And so, what do doctors have to do? Well, they gotta go to a lab, they gotta to work on cadavers, they gotta look at videos. And for most doctors it’s just not something that they’re willing to do until they’re almost forced into that process.

And some of it’s been, you know, sort of major changes as we’ve moved from, let’s say, open rotator cuff to arthroscopic rotator cuff. But even now there’s a lot of subtle changes that are occurring around us and it’s a major challenge for doctors to make that paradigm shift to try something new.

Scott: Yeah, I couldn’t agree more. And you know, when you get back to like surgical change, that’s got its own level of change and usually it’s kind of like this, “Man, I better go do this because these results look awesome, I feel like I’m getting left behind,” you know, whatever that is. Like you mentioned, an open approach to a surgery versus an arthroscopic approach, shoulder you mentioned, but knees had its time too. Right?

So, you know, this whole idea of taking care of patients without opioids, you know, you introduced yourself as really one of the…you might’ve been the first opioid-sparing orthopod. What was that like? Walk me through that.

Dr. Sigman: Oh, it wasn’t easy. You know, when I first started doing this, 7 years ago, and really started sort of touting this process, we were still knee-deep into the society of pain, which had been developed over 2 to 3 decades. And it was just very simple, “What you do hurts, you have a responsibility to care for your patient, you’re gonna use these opioids because they’re not very addictive, and there was a couple studies that came out, and basically that they’re inexpensive.” And that was the mantra.

And so, that’s where we were up against. And we were actually getting graded on how we were performing with how we were managing our patient’s pain. So, you know, there were these age-cap scores, which were surveys that were sent to patients, there were two or three questions that were specific, “How was your pain managed?” and, “are you satisfied with your pain management while in the hospital?” So, if your patients didn’t say yes, then basically you could get dinged financially, as a hospital, as to the compensation you were getting for surgery.

So it was an uphill battle. I could barely fill a room, there would be a couple people that were listening. But the good news is there’s really been, you know, a real major shift, at this point, I really sense that we have gained momentum. And the change now, when I get into a room and I give an opioid-sparing talk, there’s no less than 100 people. I just gave a great conversation out in [inaudible 00:05:05] course with the Orthopedic Value-Based Conference. Have you been out there to Newport Beach? That’s an amazing conference guys.

Scott: I’ve gotta get out there. I know about it, haven’t been there yet, and that is one that I gotta get to, I agree.

Dr. Sigman: Man, it’s an amazing group of diverse individuals coming together on a mission of creating an orthopedic value-based program. So you have industry leaders, hospital surgery center administrators, you have nurses, you have orthopedic surgeons, anesthesiologists, all sort of coming together for this mainstream group. And my argument has always been, you cannot provide an orthopedic value-based care model unless you’re providing opioid-sparing surgery.

You know, it’s interesting, I got an email today from another sort of superhero opioid-sparing friend of mine, Jenna Poppy from Corsair Pharmaceuticals. She’s always giving me little tidbits. So, Blue Cross Blue Shield from Texas did an analysis of their patients over the last several years for opioids and they did a little video sort of podcasting. And one of the snippets was that they took a look at their patients that were undergoing total knee and total hip replacement. And these were opioid-naive patients, meaning that they hadn’t been on opioids prior to their surgery. And literally 30%, or 1/3 of the patients, were still on opioids at 1 year after their hip and knee replacement.

So, that’s devastating. I mean, you know, our ideas were supposed to safely and effectively take our patients through surgery to remove their pain. So, instead of removing their pain, you’ve now got them addicted to opioids. It’s even worse than what they had when they started. So, you know, this concept of opioid minimization has to be, you know, paramount and the good news is people are finally starting to listen.

Scott: And you’re absolutely right about that. I remember being a sales rep, way back when…and this was 20 years ago and opioids, that was just standard practice, you know, “Of course you get that, you have to remove their pain.”

Dr. Sigman: You had to, you were forced to. It’s like, if you didn’t do it, then you were being a bad doc. I mean I would’ve been reported to the Board of Registration in Medicine, in my past life, if I did not continue prescribing narcotics to patients. And the board was listening to the patient at the time, not the doctor, or not the concern about opioid addiction, because they just didn’t understand how addictive medications are. Let me give you three numbers, it’s one of my favorite things to do.

Scott: Go ahead.

Dr. Sigman: I’m gonna give you three numbers, 6, 13, and 30. So, if you write a 24-hour prescription of narcotics to 100 patients, 6 of them will still be on opioids 1 year. If you provide a 10-day prescription of opioids to 100 patients, 13 out of 100 are still on opioids. And as confirmed now by Blue Cross Blue Shield in Texas, if you give them a 30-day supply, 30 out of 100 are still on opioids. They are powerfully addictive medications, we have no idea who’s gonna become addicted, and the best thing you can do is either maintain opioid-naivety or minimize the exposure of opioids to your patients to have successful outcomes.

Scott: You mentioned Pacira, which makes a product called Exparel, which is essentially a long-acting…I call it a long-acting Novocaine, I know it’s not Novocaine. A long-acting Caine which is very effective and there are a lot of other effective ways to minimize pain that do not require opioids, it just takes a little bit more work rather than just saying, “Here, take these pills.” You know what I mean?

Dr. Sigman: Yeah, it’s more work and it’s also more expensive on the front side. You know…

Scott: It is.

Dr. Sigman: You know, you see that…

Scott: Yeah, sorry. Now we’re finding like…but the real expenses, like you just mentioned those numbers, 16, 13, 30, it’s like, “Hey, there’s a lot of payments to be made for those people who are still stuck on opioids.”

Dr. Sigman: Yeah, you’re absolutely right. The expense that we have created for ourselves to society, much less the loss of life, has been overwhelming. I mean it’s billions of dollars that we’re spending on patients that have substance-use disorder, for our emergency responders to be able to maintain Narcan, to the loss of productivity in the work force for patients that have become addicted to opioids.

You know, literally, if your workers comp case and you put your patient on opioids, there’s a four times more chance that they’re not gonna return to work than if you don’t. And then, you know, the loss of absence of work and productivity has been overwhelming. It’s billions and billions of dollars to our society. So, realistically, if you’re gonna have a value-based orthopedic system, you have to do opioid alternatives to the front side, minimizing exposure, and then, hopefully, we can save lives as well as save money to the system and society as a whole.

Scott: Yeah. It’s just like I pat you on the back, you were definitely leading the pack on that screaming, you know. At some point, like you mentioned sometimes to an empty audience, like, “Stop doing this.” I wanna do a terrible job of segueing to laser therapy, which is yet another modality where another treatment…excuse me, where you have the ability to reduce pay. And I want you to kind of walk people through that and how you came up with it and what you’re doing and what it is.

Dr. Sigman: It’s one more thing that I decided to take as a challenge but I have influenced and changed the mindset of individuals across our country. So, I always start like this. So, first and foremost, suddenly, you know, as the opioid-sparing orthopedic surgeon, I’m approached cold calls with new and great ideas all the time. So, laser people found me, I did have one friend that was using it.

And we started using it in my office and I was actually very impressed and I thought, “What a great idea to be able to provide an alternative option for our patients where perhaps we might even be able to avoid surgery. If we’re gonna operate on patients, perhaps we can reduce their pain and swelling and reduce the need for opioids. And then, for acute injuries as well, perhaps we might be able to reduce their time and healing.” So all of these things are sort of where laser was born. So I started doing all my research and… So, do you have a dog or a cat, either one of you, Michael, Scott? Do you have any animals at home?

Scott: I had a dog, unfortunately it just passed away, but I’ve had dogs for most of my life and a couple of cats as well.

Dr. Sigman: So the number-one utilization of laser in America is veterinarians. And for me that was pretty profound, I mean I’ve always been an animal lover. And so, I actually approached some of the local veterinarians in my area and I said, you know, “What’s going on? How are you using this?” And they said, “Well, look. We did an ACL reconstruction on a dog, typically it would lie around either in our hospital or at home for 3 days and not move around, but what we found is, if we laser them immediately after the surgery, the dog will walk out of the animal hospital the day of the surgery.” I said, “Well, that’s kind of profound,” right? I’m like, “Dogs and cats don’t have jobs, they don’t have placebo effect, they don’t have secondary gain issues. They’re basically either better or they’re not.”

And I’ve seen a penguin with arthritis of its hip that could barely swim, get lasered and jump in the pool afterwards and be able to swim around. So, I was like, “Okay. Clearly there’s something in the physiology of these animals where it’s working.”

And then, I went out just outside of Venice, Italy, and I met with the laser manufacturer, met with Professor Monica Monici, who is one of our world’s leading authorities on cellular biology, specifically laser effects. And I basically sat down with them, over a couple of weekends, and allowed them to educate me on the basic science of how this laser works. And it really is quite profound, basic science behind laser and how it works at the cellular level is well-document.

And so, I’m gonna make you guys go back to your high-school chemistry days but ATP, which is the fuel of the cell, comes to mitochondria, which is the powerhouse of the cell, while there’s these enzymes in there and those enzymes are sensitive to light energy, specifically the very specific wavelengths of light energy. And if you apply those wavelengths, you basically increase the metabolism of the cell and it sort of wakes it up and allows it to start going into a healing mode, moving out of an inflammatory mode into a reparative mode.

And that is not guesswork, that’s not, well, you know, high in the sky, it is solid basic science that’s been assayed and you can read it and you can see it. Which for me was quite profound because I’m still tinkering with regenerative medicine, with PRP and stem cells, which is another alternative form. And I do believe that these modalities work, I’m just not sure how they work and we’re sort of waiting to understand the science better. But yeah, we do understand the laser science quite well.

And so, from there I was like, “This makes a lot of sense. We’re in the midst of an opioid crisis, we can’t use these opioids, we’re getting pushback from all these other modalities that we’re doing.” I know for a fact that patients are looking and pining for options other than surgery and opioids and I think this is a unique opportunity. Yeah, go ahead.

Scott: Yeah, sorry to interrupt you there, but you’re looking to get the lasers, you’re seeing good numbers. It’s not just anecdotal, right, it’s some good numbers. What is that tipping point where you say, “I’m gonna try this and see how it’s doing on my patients.”?

Dr. Sigman: A lot of it, for the most part…it’s funny how people learn. Okay? How doctors learn in particular. You can learn based on reading journals and reading randomized controlled trials and trying to determine whether or not what you’re gonna do is based on fact or fiction. You can go to meetings and learn from doctors one of the main ways in which I have always learned and one of the ways I’ve been willing to innovate and be a key opinion leader and champion new ideas is by being at the table with other innovators and letting them, letting all of us together, discuss options of what we’re doing. And one of these innovators comes around and says to me, “Hey, Scott, I’m doing this,” and it’s a guy that I trust implicitly. I’m like, “I’m gonna try this.”

And that’s for me has been a major way in which I’ve made changes in my clinical practice. And I had a friend who was doing the laser, so that was sort of the impetus for me to try it. And then, it was interesting, because the laser company that was manufacturing and distributing, they were selling one or two lasers off to two orthopedic groups and, you know, they would keep it in the large practice. And one thing’s for sure, if you try to get 10 orthopedists in a room and try and come up with a consensus, that will never happen. [inaudible 00:15:37]. Everybody has their own idea as to what’s right.

But at the end of the day, I said, “Look, here’s what we’re gonna do. We’re gonna take these lasers, I’m gonna take them out of my busy orthopedic practice, and I’m gonna open up a laser center where all we’re gonna do is laser people. And we’re gonna provide a high-volume ability to move patients in, provide them this alternative, you know, process of healing and make it a business model that can be successful for healthcare providers and also successful for patients. And the bells went off to the laser company and they said, “Okay, we get it. We understand this model and we wanna partner with you as we go forwards in creating orthopedic-laser franchises across the country to be able to help patients.”

Scott: Yeah, and that’s what’s interesting to me. You know, like the whole idea of not only coming up with a way to take care of a patient, which doesn’t involve popping a pill, quite frankly, and then, you took it another level. So, you didn’t just say, “Hey, I’ve come up with a way to help reduce pain, the technique using the laser doesn’t take a lot of time either.” I remember you mentioning, at the meeting we were at in Las Vegas, that, you know, a lot of the people you take care of are hard-working people, and telling them that they need to take off for 6 to 12 weeks for a surgery or a regimen, that’s asking a lot, you know, of people who need to just keep working. And you know, with this particular laser therapy, if I remember correctly, it was, “How long is the whole therapy?” and, “how quickly do they feel the relief, the pain relief?”

Dr. Sigman: Yeah, Scott, great question. So, our laser is really quite unique on the market, it’s a pulsed laser so it goes on and off 1,500 times a second, which allows the laser energy to penetrate about 4 to 5 centimeters below the tissue, so it’s perfect for orthopedic conditions. But because it’s pulsed, it doesn’t generate significant heat energy, so there’s no concern about complications or skin heating up or creating blisters or skin problems. The sessions take anywhere 8 to 10 minutes. And literally, you can’t feel it, you can’t see it, you can’t hear it, it’s completely painless. We are FDA-cleared, I wanna mention that too so people don’t think that it’s experimental.

And the way it works is it works at the cellular level, as I initially described, and that response at the cellular level has to build up over time as well. It’s not like a massage or acupuncture where you walk out and you feel immediately better, as a general rule, it takes about 4, 5, or 6 treatments before you really start seeing significant relief. And by the time you get out to 9 or 10 treatments, which is what we typically will recommend for chronic disease processes, people are really seeing great pain relief.

And, you know, it’s not a medication, it’s completely non-toxic. It doesn’t affect anywhere else in the body, it’s only affecting the zone in which you’re lasering. And it’s laser-light energy, so like we’re getting pain relief 10, 11, 12 months for many patients. And then, they’ll come back in for maintenance treatments, because why not? I mean, again, it’s laser-light energy, it’s not toxic, it can’t hurt you. There’s a great success in keeping them out there as well.

Scott: So here’s this technique. It’s working for you, you’re happy with it. And I don’t think people are realizing this, what you’ve done is take it to the next level, Dr. Sigman, where you basically said, “Hey, I’m gonna come up with a model for an orthopod to utilize,” this franchise model. So that you’ve actually got it down to the layout of the clinic. Correct?

Dr. Sigman: We want orthopedic surgeons to be orthopedic surgeons? Right? I mean why do most people fail when they buy a franchise? It’s because they have an area of expertise, they have some extra money, and then, they gotta figure out what they’re gonna do. So what do they do? They open up a restaurant or they open up, whatever it is, a pizza shop or making hamburgers or cupcakes. It’s not anything that they’re familiar with. We’re partnering with orthopedic surgeons across the country and all we’re doing is asking them to continue on their path of doing what they do but now add a new modality of treatment as an option for your patient.

We have the franchise model. You’re not buying lasers, we’re very clear about that. We’re very selective at who we partner with, we wanna make sure that the orthopedic surgeons that we’re partnering with have an understanding of laser, as well as an entrepreneurial spirit, and are innovators in their field. Now, we do have outside orthopedic surgeons like pain-management specialists that can partner in as well, so it doesn’t have to be an orthopedist.

But what we do is we’re selling you a business, we’re selling you the absolute franchise and it’s turnkey. So you’re gonna get your lasers, you’re gonna get your computers, we partner with a company that actually knows your exact location. We have a commercial realtor that finds your location. We then build everything out in California, we ship it out on a pallet with instructions for your general contractor to put everything together.

My laser partners then come in. We have the software that’s all set up, you’re not running an EMR, you don’t need an EMR, but we do have a software package that you’re running your business. It’s more like a hair salon or a nail salon, as far as how the patients move through. And then, basically we provide all of the technical aspects of training your laser technicians and understanding the lasers and how they work. So literally, we try to make it as simple as possible to allow you to open up a facility within a couple of months, and then, you can start healing with alternative treatment.

Scott: It’s just amazing to me. And that’s what…you know, I remember leaving the conference and the things that really stuck with me wasn’t just that you had come up with yet another way to reduce pain without opioids, quite frankly, something that the average person could take advantage of without having to take themselves out of getting paid. You know, you could be there for an hour and just go back to work, it’s not that big a deal. That’s a huge deal as well. And then, you’ve empowered caregivers, like, “Here’s the model. I’ve got it all figured out. Here’s the layout of the place, it’s already built, we have people who’ll figure everything out for you. All you need to do is continue to provide care.

Dr. Sigman: And you can self-refer. I mean it’s quite fascinating, it’s one of the rare opportunities for orthopedic surgeons. Laser therapy, as of this moment, does not have a CPT code. And, you know, I’m sure you’re familiar with the designated health services, BMS. And so, physical therapy under the eyes of CMS is if you have a CPT code for physical therapy. So there is no CPT code for laser therapy so there are no federal stark law concerns. So you’re able to self-refer to a facility.

Now, I wanna be very clear that each and every state in our union has its own regulatory issues that they have, many states will have many stark laws, some will, some won’t. And so, we highly advise our potential franchisees to seek legal counsel from a health-care attorney in their state so they understand the lay of the land. But as a general rule amongst most of the states across our country, you can own this facility, you can then self-refer patients to the facility, generate passive income, and then also be able to help heal your patients with an alternative treatment. It really is sort of the perfect storm within this opioid crisis right now, to be able to give a great option to patients and doctors.

Scott: That’s just fantastic. I just love that you’ve kind of used that noggin for some good thoughts on how to help people. And my perspective on all this is, if you do wanna learn a little bit more about Dr. Sigman, #followthefro is a good way to do that. He’s on LinkedIn, you’re on Twitter, definitely you could type in OrthoLazer and learn a little bit as well. Dr. Sigman, I really do appreciate the time that you take to go out. Because you’re on the road quite a bit, not just with me on this podcast for a half-hour, but you’re on the road quite a bit talking about this as well. Correct?

Dr. Sigman: Yeah, I’ll be down Washington DC next Thursday and Friday. I’ve been invited down to the NIH National Institutes of Health to develop both an acute and chronic care pain pathway for a new potential opioid alternatives. So, really excited about that opportunity. I’ll be down at the American Academy of Orthopedic Surgery in Orlando the following week where OrthoLazer we’ll have our booth. You can find me on LinkedIn, Scott A. Sigman, M.D. is how you find me. Always trying to push the envelope and change the paradigm on both innovation and opioids-barring minimization. Also, Facebook and my personal website’s scottasigmanmd.com and ortholazer.com as well.

Scott: There we go. All right, well, Doc, thank you very much for taking the time to speak with me. I sincerely appreciate it.

Dr. Sigman: This has been great. Michael and Scott, thank you so much for the opportunity. Greatly appreciate it.

Announcer: Thanks again for tuning into “The Paradigm Shift of Healthcare.” This program is brought to you by P3 Inbound, marketing for ortho, spine, and neural practices. Subscribe on iTunes, Google Play, or anywhere you listen to podcasts.