The AAOS (American Academy of Orthopaedic Surgeons) has recently sponsored some remarkable multimedia public service campaigns. You may remember the recent “Decide to Drive” initiative about distracted driving /texting. Well, their newest is “Painkillers are easy to get into. Hard to escape.” Included in the AAOS statement, the U.S. Department of Health and Human Services reports on an average day in the U.S., more than 650,000 opioid prescriptions are dispensed and 78 people die from opioid-related overdose. It is considered an “epidemic.” We all have relatives, friends, and patients who have been caught up in and succumbed to the detrimental effects of drug addiction.
As the AAOS highlights the dangers of opioid abuse, I think of my own experiences with pain medications. As Orthopaedic Surgeons, we rarely see a patient whose chief complaint is something other than pain. Back pain, knee pain, shoulder pain, or recent injuries with pain are common presentations. I have long tried my best to run a non-narcotic spine practice. My policy is to not give narcotics for any prolonged period of time. I attempt to give pain relievers for 2 weeks after injury or surgery. Of course there can be exceptions. Our group practice has hired RNs and PAs who help us doctors with pain medication phone calls so as not to turn patients away but to respond with compassion and knowledge and alternatives. We make sure those answering the pain phone calls understand our policies and are trained and alert to possible problems. The Alabama physician database for narcotic prescriptions has been very helpful.
I developed a concern for pain medications early in my practice. I found it a very good idea to closely evaluate those patients experiencing severe pain so as not to overlook things, such as, cast tightness-compartment syndrome or tissue ischemia. Even today, when evaluating neck or back pain I do my best to figure out what the pain producer is. I saw early in my residency training that doctors who gave out a lot of narcotics did not have as good of patient results as those physicians who were more deliberate and concerned in giving narcotics. I have forever tried to understand the neuroscience and psychology of pain. It is very complex, similar to other addictions, for example, gambling and nicotine use. It doesn’t seem to make sense. I have had many conversations with colleagues I consider experts and who, I feel, have genuine interest in treating painful problems. Some colleagues within my own practice and other health professionals who specialize in pain management locally here in the city. One fellow colleague, who now is retired, had a common sense approach to pain patients. He would tell me that he had trouble sorting patient problems out until they were weaned off narcotics. I saw this time and again seeing spine consults for him. And the queer thing about it was many times once the patient was off narcotics the pain was greatly diminished or gone. Go figure… At any rate, I am in the autumn of my career; it is unlikely I am going to come to a thorough understanding of this complex issue. The way I understand this narcotic addiction is as follows. There are autonomous pleasure centers in our brains that crave fulfillment and they can avoid our normal healthy control of our cravings. Narcotics are especially prone to give one the best feeling they have ever experienced. So, these pleasure centers love opioids, sometimes to our detriment.
The AAOS states that patients taking opioids prior to surgery have greater post-surgical pain and face a higher risk of pneumonia, over-sedation and even death. It is my understanding the pain receptors are already loaded up so sometimes even giving greater doses doesn’t help with pain relief, but causes more sedation.
The AAOS suggests that patients:
The first few days after injury or surgery are the worst and will improve day-by-day.
Use ibuprofen, acetaminophen, and ice.
I cannot tell you how many times a patient has told me someone has taken their pain medications
We all go into patient care to help others and ease suffering. Just as the tagline: Less Pain. More Living. It may be best practice to be particularly cautious with opioid medications. I mean this sincerely when I say good luck treating pain patients, prescribe safely, try to avoid pitfalls, and do seek expert advice.
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