Study in JAAOS finds psychologic factors have greater influence on disability, satisfaction with treatment, and pain management
According to a study published in the July issue of the Journal of the American Academy of Orthopaedic Surgeons, no association exists between opioid intake and disability following surgery for ankle fracture. The study also found no link between opioid intake and satisfaction with treatment or pain management. Instead, the researchers found that the factors most associated with disability, treatment satisfaction, and reports of pain at suture removal and at 5 to 8 months after surgery were pain anxiety and catastrophic thinking.

The findings suggest that patients with ankle fractures may be able to use fewer opioids than commonly are prescribed and will fare just as well in terms of levels of disability and treatment satisfaction as patients who take greater amounts of opioids. The findings also point the way to better pain relief: care and interventions that cultivate peace of mind.

The study involved 102 patients evaluated at the time of suture removal (within 4 weeks after injury) after open reduction and internal fixation of an ankle fracture. Sociodemographic information, trauma-related factors, and scores on questionnaires assessing disability, pain, and satisfaction were recorded. Trauma-related factors included mechanism of injury and fracture type. Treatment-related factors were opioid use before surgery and at the time of suture removal.

At suture removal, 83 of 99 patients (84 percent) used opioids, and at 5 to 8 months after suture removal, 14 of 59 patients (24 percent) still used opioids. With regard to disability, decreased disability at suture removal was independently associated with being married, with sports injuries, and with less catastrophic thinking, but was not associated with opioid intake. At 5 to 8 months after suture removal, decreased disability was independently associated with lower pain anxiety at the time of suture removal (Table 1).

The authors reported that opioid intake was not associated with treatment satisfaction. Greater treatment satisfaction at suture removal was independently associated with less catastrophic thinking. At 5 to 8 months after suture removal, no variables were associated with treatment satisfaction (Table 2).

Furthermore, no association was found between opioid intake and satisfaction with pain management; however, greater satisfaction with pain management at suture removal was independently associated with being widowed/separated, with being nonsmokers or non–tobacco users, and with having less catastrophic thinking. At 5 to 8 months after suture removal, greater satisfaction with pain management was independently associated with less catastrophic thinking at suture removal.

Greater pain at rest at the time of suture removal was independently associated with more catastrophic thinking and with more opiate use at suture removal. At 5 to 8 months after suture removal, more pain at rest was independently associated with injuries other than slips, trips, or falls or sports-related injuries, but not with opioid use. More pain with activity at suture removal was independently associated with more opioid use at suture removal. At 5 to 8 months after suture removal, more pain at rest was independently associated with injuries other than slips, trips, or falls or sports-related injuries.

In discussing the results, the authors note that "previous studies have demonstrated that patients who take more opioids after fracture management [in general] report greater pain intensity and less satisfaction with pain relief" and that they sought to determine if this finding would hold true for ankle fracture specifically. Disability at suture removal and at 5 to 8 months afterward was not diminished by opioid pain relievers.  Disability was related to mindset: "Maladaptive responses to nociception had a statistically significant correlation with disability. In other words, the tendency to misinterpret or overinterpret nociception as damage or doom—greater catastrophic thinking—was associated with greater disability."

In light of this finding, the authors write, "The need to move away from an opioid-centric model for pain management is illustrated by the fact that 24 percent of the patients included in this study were still using opioid medication 5 to 8 months after suture removal. Our results affirm efforts to move away from the opioid-centric model of pain management and proactively address stress, distress, and ineffective coping strategies. Our results also demonstrate the need for a comprehensive approach to pain relief after surgery, including optimization of the patient's mindset and circumstances (with effective coping strategies being most important) in addition to the use of analgesics, elevation, ice, and other physical strategies."

In an interview with AAOS Now, David Ring, MD, PhD, the corresponding author for the study, discussed the results and their implications.

AAOS Now: What prompted you to undertake this study?

Dr. Ring: We conducted this study to continue to amass scientific evidence on pain relief with the hope that it will help change our culture and increase patient safety and comfort. This study addressed whether opioids allowed patients recovering from ankle fracture fixation to be more active (less disability), and we found that they did not. Patients were more comfortable and more active if they were in a better mood and had more-effective coping strategies. Studies such as this consistently show how important it is to address and ameliorate any stress or distress in our lives and to spend time every day cultivating the most effective possible coping strategies. 

AAOS Now: What had previous research shown?

Dr. Ring: Before this study, I and some of my Dutch colleagues decided to study cultural differences in the use of opioids and found that almost nothing was written about the topic. We catalogued what patients in the Netherlands took after ankle and hip fracture surgery (acetaminophen) compared to what patients in the United States took (oxycodone). Because we didn't know if the patients in the Netherlands had been suffering, we repeated the comparison prospectively among patients undergoing ankle fracture fixation in both countries. We found that patients in the Netherlands who took just acetaminophen were equally or more satisfied with pain relief after surgery and experienced similar or less pain compared to U.S. patients who took oxycodone.

We also found a way to track the exact amount of opioid medication used by inpatients in the United States and found that, according to the results of three studies, people experience more pain when they take more opioids, regardless of the level of nociception (number or type of surgeries or fractures). We also found that pain self-efficacy (the sense that everything will be fine in spite of pain) and better mood (fewer symptoms of depression) were the most effective pain relievers. Additional studies revealed that increased pain and disability were associated with greater psychological distress and less effective coping strategies and that ongoing opioid use long after the healing is nearly complete is associated with psychological factors.

AAOS Now: Please elaborate on the study's finding that "maladaptive responses to nociception" and catastrophic thinking had a correlation to disability.

Dr. Ring: Humans are wired to respond to pain by preparing for the worst (catastrophic thinking). When we take that too far, we begin to feel helpless and overprotective. This maladaptive response to nociception is strongly associated with experiencing more pain and more limitations. The converse of catastrophic thinking is self-efficacy: The sense that one can manage recovery. Examples of catastrophic thinking after ankle fracture fixation may include imagining the pain means the wound is splitting open, the implanted metal is loose, or there is an infection. More importantly, it's imagining never being able to do your job or beloved activities. In contrast, self-efficacy includes thoughts such as "The surgical site is sore, but my body just needs time to heal," and "In time I'll get back to my activities, even if the ankle isn't as good as it was before."

AAOS Now: You note that 24 percent of patients were taking opioids months after surgery, demonstrating the need for a comprehensive approach to pain relief after surgery. What does doing this entail?

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Dr. Ring: Most of the world achieves pain relief with very few opioids and we should do the same. Opioids should be taken in the smallest possible doses for the shortest possible time and leftover pills should be placed in a repository so they are not diverted or misused. Those of us with the ability to prescribe opioids electronically can give small amounts of opioids after moderate to large surgery (using acetaminophen and ibuprofen alone for minor surgery), with the ability to add more later only if needed and only if it fits within the department or practice strategy for limiting the total amount of opioids for a given procedure. We should discuss pain relief with our patients and prepare them for recovery. Additionally, there should be a department or practice-wide upper limit on the amount of opioids prescribed for a given class of procedures. We can screen patients for stress, distress, and less-effective coping strategies (as well as increased risk of misuse) and address these prior to scheduling surgery. We can also phone patients the day after surgery to make sure everything is on course, assuring them that we care about their comfort.

AAOS Now: How can the study's findings be applied both to providing more effective pain relief and less disability after ankle fracture surgery and to reducing unnecessary or excessive opioid consumption? How global would these applications be beyond ankle fractures?

Dr. Ring: The collective evidence suggests that the most effective way to help patients get comfortable is to first earn their trust and then help them relieve their stress, elevate their mood, and cultivate more-effective coping strategies. To that end, orthopaedic surgeons can practice more-effective communication strategies, plan more comprehensive pain relief strategies, and enlist the help of social workers, psychologists, and other experts in human illness behavior.

Dr. Ring's coauthors of "Association Between Opioid Intake and Disability After Surgical Management of Ankle Fractures" are Abigail Finger, BA; Teun Teunis, MD, PhD; Michiel G. Hageman, MD; Emily R. Ziady, BSc; and Marilyn Heng, MD, MPH, FRCSC.

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org