Nociception is the physiology of actual or potential tissue damage. Laceration, sprain, strain, dislocation, fracture, and surgery all create nociception.
Pain is the cognitive, emotional, and behavioral response to nociception. The degree of variation in pain for a given nociception is remarkable. As orthopaedic surgeons, we see injured athletes and wounded soldiers with significant tissue damage but little pain. We also see patients who have substantial pain and no detectable nociception. What’s going on?
Humans learn to filter nociception so that they don’t experience much pain. A post-workout ache or a sustained yoga stretch feel healthy and aren’t bothersome enough to change behavior. Bumps, bruises, strains, and sprains are an expected part of sports that rarely keep athletes from the game. Dental cleanings, injections, and deep tissue massages are tolerated because people have the sense that these nociceptions are beneficial.
The ability to channel nociception so that it is less painful seems to vary between individuals and cultures, and according to circumstances. For instance, after surgery to repair a fractured ankle, patients in the Netherlands are satisfied with nonopioid pain medication (usually acetaminophen). In fact, they experience the same pain intensity and satisfaction with pain relief as their counterparts in the United States who typically take one of the strongest available oral opioids (oxycodone).
Based on my travels, interactions with visitors from around the world, and the fact that an estimated 80 percent to 90 percent of the world’s opioids are consumed in the United States, most patients in other countries take little or no opioid pain medication after skeletal injury or surgery. Yet they are comfortable and satisfied with pain relief. How can this be?
Mindset and circumstance
The evidence is consistent and compelling: Pain intensity is determined more by mindset and circumstances (stress, distress, and coping strategies) than by the degree of pathophysiology (nociception). Indeed, among patients recovering from fracture surgery, greater pain intensity correlates with intake of more (not less) opioids, is not related to the type or number of fractures, and is relieved by greater self-efficacy (the sense that things will be alright). In other words, when Dutch patients break their ankles and have surgery, they think, “This is going to hurt.” But it seems that many Americans who break their ankles and have surgery wonder, “Why am I hurting?”
So what is the best use of opioids for pain relief?
Since the discovery of opioids, humans have struggled to balance their pain-relieving and addictive properties. The most recent iteration is the increased use of opioids for chronic, nonmalignant pain, which started in the 1990s. Pharmaceutical companies now face lawsuits for alleged inappropriate marketing practices.
These trends affected healthcare providers, leading to advocacy for greater use of opioids for pain control as embodied in the American Pain Society’s and the Veterans Administration’s widely adopted “Pain is the fifth vital sign” initiative.
The increase in the number of prescriptions for opioid pain relievers was accompanied by a corresponding increase in opioid abuse and opioid-related deaths. This, in turn, led to resurgence in the use of heroin. Many of the doctors that helped create the opioid epidemic now regret the role they played.
Undoing the harm
It’s much easier to create such an epidemic than it is to resolve it. In fact, many physicians are concerned that the appropriate use of opioids will decrease the patient satisfaction scores that are increasingly being used to rate the quality of their care.
These are difficult discussions to be sure but, as orthopaedic surgeons, we should use lessons learned from efforts to limit the prescription of antibiotics for upper respiratory infections and the use of magnetic resonance imaging for low back pain. Among the things necessary to reduce the use of opioids for pain relief are the following:
- clear explanations of the rationale for limited opioid use that are understandable to people regardless of their level of health literacy, combined with optimal empathy and compassion (effective communication strategies)
- guidelines, policies, and protocols for limited and appropriate use of opioids for acute injury and postsurgical pain (to depersonalize the discussions) and in favor of nonopioid methods for pain control
- improved training and expectation setting prior to elective surgery and during the recovery period from injury and emergency surgery
- partnerships with other caregivers, particularly if patients are on regular opioids, have a history of abuse, or take Suboxone
- routine screening and treatment of stress, distress, and ineffective coping strategies
Each orthopaedic practice needs to establish a consensus about acceptable limits for a first and a second opioid prescription after surgery. That must become official policy, so that what is done in the office is standardized. When a patient requests medications outside the policy, everyone in the practice should know and explain that the policy is for the patient’s benefit and cannot be violated.
Patients who are having more pain than expected should receive phone calls and be seen in the office as often as necessary—not only to rule out adverse events such as infection or compartment syndrome, but also to talk them through the pain. Pain triggers our human “safety system,” making us feel protective and helping us prepare for the worst. It can be difficult for patients in pain to shake the feeling that something is wrong. At its worst, this amounts to a type of panic attack. Positive, soothing, empathic expertise can really help people feel comfortable.
It can be argued that fear of these phone calls and discomfort with our abilities to soothe patients who have unexpected responses to pain have contributed to increased prescription of opioids. As physicians, we need to be healers, not just technicians. At the very least, we need people on our team who have these skills. Preoperative coaching and preparation as well as postoperative coaching and companionship may help reduce pain more than increased opioids.
If it was a culture change that created the current opioid epidemic, only a culture change led by physicians unafraid to limit opioid prescriptions will solve the epidemic. It’s up to us to learn how to treat pain with less dependence on opioids.
David C. Ring, MD, is a member of the AAOS Patient Safety Committee. He can be reached at email@example.com