Pain Relief: What Can We Do?

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.

So what is the best use of opioids for pain relief? 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 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.

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