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Fig. 1 Comparison of percentages of patient responses to the statement “Pain doesn’t bother me as much as it does most people” between the top 25 percent and bottom 75 percent of postoperative opioid pill consumers.
Courtesy of Rachel Shakked, MD

AAOS Now

Published 8/1/2019
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Terry Stanton

Study Illustrates Self-reported Low Pain Tolerance Linked to Increased Opioid Consumption after Foot and Ankle Surgery

Patients who viewed themselves as having a low pain threshold took more opioid medication after foot and ankle surgery than those with a high self-reported pain threshold, according to a study presented at the American Orthopaedic Foot & Ankle Society Specialty Day during the AAOS 2019 Annual Meeting.

Daniel Fuchs, MD, of the Rothman Institute, presented the study, which was a retrospective follow-up of a prospective cohort study (Saini et al., 2018). Rachel Shakked, MD, also of Rothman, was the primary investigator. She commented: “In light of the current opioid crisis, orthopaedic surgeons are attempting to find a balance between appropriately treating patients’ pain while minimizing narcotic prescriptions. There is no reliable way to predict how many narcotic pills a patient will need after surgery. In a prior study from our institution, we identified several objective factors about patients and procedures to help determine narcotic pill requirement after surgery. This study aimed to evaluate patient perception of their pain tolerance and assess whether this is related to narcotic pill quantity after surgery.”

The investigators contacted patients from the previous study postoperatively to complete a survey, which included responding to the statement “Pain doesn’t bother me as much as it does most people” to provide a qualitative assessment of their pain tolerance. Patients scored their pain threshold on a scale of zero to 100, with zero being “very pain intolerant” and 100 indicating a “very high pain tolerance” to generate a quantitative assessment.

A total of 700 patients responded to the survey, including 457 females (65.3 percent); the average patient age was 50.9 ± 15.5 years (standard deviation). Patients’ mean response to the quantitative assessment of their pain threshold was 62.9 ± 25.8. Those participating in the survey reported taking an average of 21.9 ± 17.7 pills, whereas the mean number of pills dispensed to the cohort was 43.7 ± 16.64 pills. The top 25 percent of the cohort (n = 176) comprised all patients who reported taking 34 or more pills. The average number of prior orthopaedic surgeries was 1.8.

Additionally, 22.6 percent of patients reported that they had previously taken narcotic pain medication before surgery; 8.3 percent reported consulting with a pain management doctor in the past, and 8.1 percent indicated that they had received narcotic pain medication to manage chronic pain. Two-thirds of patients stated that they are aware of government regulations regarding opioid medications.

Pain tolerance: qualitative versus quantitative

In comparisons of patient survey responses between the top 25 percent and bottom 75 percent, the top 25 percent of pill consumers had significantly less agreement with the qualitative assessment of pain tolerance (P = 0.026), indicating that they did not believe they had a high pain tolerance and were significantly more likely to have taken narcotics prior to foot and ankle surgery (P = 0.026) compared to the bottom 75 percent of consumers. However, there was no significant difference in the quantitative assessment of pain threshold between the top quartile of opioid consumers and the lower 75 percent of the cohort, with mean values of 63.4 and 61.6, respectively (P = 0.443) (Fig. 1).

Fig. 1 Comparison of percentages of patient responses to the statement “Pain doesn’t bother me as much as it does most people” between the top 25 percent and bottom 75 percent of postoperative opioid pill consumers.
COURTESY OF RACHEL SHAKKED, MD

The top 25 percent were dispensed more opioid pills (P < 0.001) and were younger (P < 0.001) than patients in the bottom 75 percent. The top 25 percent of opioid consumers required opioid medications for more days postoperatively (P < 0.001), felt they were not given adequate postoperative pain medication (P < 0.001) (Fig. 2), more commonly stated that surgery was more painful than they had expected (P < 0.001), and were less satisfied with postoperative pain management (P = 0.004).

Fig. 1 Comparison of percentages of patient responses to the statement “Pain doesn’t bother me as much as it does most people” between the top 25 percent and bottom 75 percent of postoperative opioid pill consumers.
Courtesy of Rachel Shakked, MD
Fig. 2 Comparison of percentages of patient responses to the question “Do you feel you were given an appropriate amount of pain medication?” between the top 25 percent and bottom 75 percent of postoperative opioid pill consumers.
Courtesy of Rachel Shakked, MD

Fig. 2 Comparison of percentages of patient responses to the question “Do you feel you were given an appropriate amount of pain medication?” between the top 25 percent and bottom 75 percent of postoperative opioid pill consumers.
COURTESY OF RACHEL SHAKKED, MD

Patients who had less agreement with the qualitative self-assessment of pain tolerance, indicating a lower pain threshold, took significantly more opioid pills. Furthermore, patients in the top quartile of opioid consumption had significantly less agreement with qualitative self-assessment of pain tolerance than the bottom 75 percent, indicating that the patients who take the most opioid medication postoperatively are more likely to say they have a lower pain threshold. There was not a statistically significant association between the quantitative pain tolerance self-assessment score and postoperative opioid consumption. “Therefore, use of the qualitative self-assessment question may be the preferred method of assessing patients’ pain tolerance for use in formulating a postoperative pain management plan,” the authors wrote.

Self-assessment and opioid education

Overprescription of opioids after foot and ankle surgery may create opportunities for pill diversion, Dr. Shakked said. “Although patients are encouraged to dispense of any excess narcotics at a police station or in the trash mixed into coffee grounds or cat litter, many patients hold onto the extra medication for usage in case their pain recurs or to have in case of another injury in the future. Even without any malicious intent, the excess narcotic pills may be at risk for theft or abuse by another household member. Identifying just the right amount of pills to prescribe to avoid excess is really the goal to minimize orthopaedic surgeon contribution to the opioid crisis.”

The study findings indicate that patients’ self-assessment of pain tolerance may be useful to surgeons when they are personalizing patients’ postoperative pain management regimens after foot and ankle surgery.

“Agreement or disagreement with the validated statement ‘Pain doesn’t bother me as much as most people’ may be helpful in the clinical setting to determine how many narcotic pills to prescribe for perioperative pain control,” Dr. Shakked said. “Using this subjective measure of pain tolerance in addition to other factors such as procedure type, patient age, and procedure location may allow for a more accurate prediction of narcotic pain medication usage after surgery.”

Drs. Fuchs and Shakked’s coauthors of “Self-Reported Pain Tolerance and Opioid Pain Medication Use after Foot and Ankle Surgery” are Laura Sokil, BS; Elizabeth McDonald, BA; David I. Pedowitz, MD, MS; Steven M. Raikin, MD; Ryan Rogero, BS; Brian S. Winters, MD; and Joseph N. Daniel, DO.

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

References:

  1. Saini S, McDonald EL, Shakked R, et al: Prospective evaluation of utilization patterns and prescribing guidelines of opioid consumption following orthopedic foot and ankle surgery. Foot Ankle Int 2018;39:1257-65.
  2. Gupta A, Kumar K, Roberts MM, et al: Pain management after outpatient foot and ankle surgery. Foot Ankle Int 2018;39:149-54.
  3. Sokil LE, McDonald E, Rogero RG, et al: Self-reported pain tolerance and opioid pain medication use after foot and ankle surgery. Foot Ankle Ortho 2019;4. doi: 10.1177/2473011419S00006.