From ancient precepts such as the Hippocratic Oath, which promises no harm to the principle of no malice in modern bioethics, the doctor’s mission includes working to help alleviate suffering and avoid making it worse. But in our increasingly complex healthcare and data environment, avoiding unintentional harm can be harder than one might expect.
I went to medical school in the late 2000s and in the first half of 2010. During this decade, pain was highlighted as the “fifth most important vital sign,” placing it in the hierarchy of important survival indicators along with heart rate, blood pressure, body temperature, and respiratory rate. Pain has historically been undertreated in a system that is not patient-centered, and patient advocates rightly lobby for increased focus on this aspect of the patient experience.
Unfortunately, the medical community’s response to this is flawed by drug-based and lacking nuance. Fueled by the insidious behavior of opioid manufacturers, these drugs have played an overly prominent role in treating pain. We have been told repeatedly in medical school that as long as it is a pain medication, there is no addiction to drugs, and that there is a risk of addiction only when opioids are taken without pain. This turned out to be clearly untrue.
As residents trained in major academic medical centers with their own independent orthopaedic specialty hospitals, we help care for a steady stream of patients undergoing a variety of orthopaedic surgeries, large volumes Elective total hip and total knee arthroplasty. Anyone who has had a total knee replacement or cared for a knee replacement will know that it can be an extremely painful experience.
In-house staff were the first providers asked to address inadequate pain control. Each patient ordered opioid analgesics as needed. Early on, these were even intravenous opioids, usually in the form of a patient-controlled analgesic pump that delivered a shot of opioid directly into a patient’s vein at the push of a button. How patient centered! Anyone uncomfortable with standard doses receives pain management counseling and often leaves the hospital with a heavy opioid prescription from a pain doctor.
In the late 2010s, the medical community became increasingly aware that we were harming our patients. Not only is opioid use a delicate blunt instrument, but with the rise of synthetic opioids, opioids are wreaking havoc on communities within the confines of the epidemic.
Plastic surgeon ranks third among medical specialties for opioid prescribing. As prescribers, we have a lever to influence the amount of opioids in our community. Patients often save unused prescription pain medication “just in case.” Unfortunately, these may be used by other family members or moved to the street.
Opioids should not be at the heart of our arsenal of pain relief technologies. We can do better for our patients and communities while maintaining focus on the patient experience and the adequacy of pain control.
My experience with opioid-free anterior cruciate ligament (ACL) reconstruction confirms this. For over a year, I have not prescribed opioid pain relievers to anyone under the age of 25 undergoing ACL reconstruction. I advised all patients and their families that I would prescribe an opioid if necessary, but no one took my offer. We collected Visual Analogue Scale (VAS) pain scores periodically at 2 weeks postoperatively. Far from increasing, these numbers decreased slightly.
How do we manage this? All patients met with a physical therapist before and 2 days after surgery. They used transcutaneous electrical nerve stimulation (TENS) before and after surgery. They get a local anaesthetic block from one of our anaesthetists, supplemented by local injections during the procedure. They provide continuous cryotherapy using chillers. Standard drug prescriptions include the non-steroidal anti-inflammatory drugs (NSAIDs) acetaminophen and gabapentin. A cannabinoid is also recommended. This is cannabidiol (CBD) for our patients without tetrahydrocannabinol (THC), the active ingredient in cannabis.
With this multimodal approach, we effectively eliminated opioids from ACL surgery in young adults without compromising pain control.
However, the most important interventions cost no money and have no side effects. This is a shift in mindset. The mentality of the doctor and the mentality of the patient. As physicians, we need to let go of the idea that opioids need to be “just in case.”
Patients want to know that their pain will be controlled after surgery. Briefly discuss this and commit to making reasonable efforts to control (rather than eliminate) pain so that patients can undergo surgery without the fear and anxiety of uncontrollable pain. Without devaluing or undermining the fact that a patient’s pain can be very real and unbearable, we must understand and communicate that the pain experience is influenced by many social, emotional, and neurophysiological factors.
We can help our patients choose a pain experience in which they have agency that does not cede to the pain itself or to the physician, and in doing so, reduces the risk to our patients and community harm.
Michael Day, MD, is a plastic surgeon.
This article appeared in KevinMD.