Liposomal Bupivacaine to Treat Postoperative Pain: Comment

We commend Ilfeld et al.¹  for their comprehensive review regarding the clinical effectiveness of liposomal bupivacaine when administered via infiltration or peripheral nerve block for postoperative analgesia. Since its approval by the U.S. Food and Drug Administration (Silver Spring, Maryland) in 2011, liposomal bupivacaine has been widely adopted and its clinical applications expanded.¹  In the midst of the opioid epidemic, it is easy to understand how long-acting, nonopioid alternatives like liposomal bupivacaine have been eagerly embraced by many physicians. Along with many regional anesthesiologists, we have remained open to the concept but skeptical of the results. The considerable increase in randomized, controlled trials over the last few years has not only shown that the “evidence fails to support the routine use of liposomal bupivacaine over standard local anesthetics,”¹  but it is also fraught with bias.¹  Not limited to the anesthesiology literature, these negative results have been reproduced in other specialties as well.^2–4 

With high-quality studies and a meta-analysis demonstrating that liposomal bupivacaine is not clinically superior to bupivacaine hydrochloride in pain score or length-of-stay measures,⁵  one would expect to see an according decline in purchasing, as the 100-fold increase in the cost of liposomal bupivacaine is difficult to justify.¹  On the contrary, sales and revenue from liposomal bupivacaine continue to grow,⁶  undoubtedly owing to an aggressive marketing campaign. We have seen first-hand the results of this campaign, as many physician colleagues who are grounded in evidence-based medicine have shifted their practice to anecdotal medicine, insisting that liposomal bupivacaine exhibits superior pain control and leads to clinically significant reduced length of stay. Perhaps the dose influences their observations: We suspect that they are injecting the maximum dose of liposomal bupivacaine (i.e., 266 mg), while using a lower dose of nonliposomal bupivacaine.¹  We have additionally observed that liposomal bupivacaine usage tends to be an institutional decision: If the hospital system has decided to purchase this expensive product, then surely it ought to be used. And so, as more practices and hospitals are infiltrated with liposomal bupivacaine despite an absence of strong evidence, where do we go from here?

As physicians, we must strive to practice evidence-based medicine and use evidence such as that presented by Ilfeld et al.¹  and Hussain et al.⁵  to defend against inappropriate and wasteful healthcare costs. However, distinguishing between objective data and marketing bias may pose a challenge for providers seeking to stay abreast of the current evidence in their field, given the prominent role the industry plays in medical education.⁷  Not too long ago, we witnessed the perils of the pharmaceutical industry’s influence on medical education and practitioners and how this ultimately helped fuel the opioid epidemic.^8,9  Nowadays, in our determination to optimize postoperative pain control with nonopioid alternatives, are we repeating the missteps of the past by allowing the industry to again influence our practice without high-quality evidence? The continued intersection of the industry with medical education places us at risk of propagating non–evidence-based practices that may translate into little benefit, potential unforeseen harm, and unnecessary costs on an already taxed healthcare system.^8,9 

The authors declare no competing interests.