Primum non nocere. First, do no harm.
All doctors know this creed. From ancient precepts such as the Hippocratic oath promising to refrain from harm, to the modern bioethical principle of nonmaleficence, the call for physicians involves striving to help alleviate suffering and to avoid harm. make it worse. In our increasingly complex healthcare and data environment, avoiding unintended harm can be harder than you might expect.
I went to medical school in the late 2000s and completed my residency in orthopedic surgery in the first half of the 2010s. It was a ten year period in which pain has been highlighted as a “fifth vital sign”, placing it in the hierarchy of crucial indicators of life along with heart rate, blood pressure, temperature and respiratory rate. Pain had always been contracted out in a system that was not patient-centric, and patient advocates rightly lobbied for more attention to this aspect of the patient experience.
Unfortunately, the medical community’s response to this deficiency was pharmacy-based and lacking in nuance. Stimulated by the insidious actions of opioid drug manufacturers, these drugs have played far too important a role in the treatment of pain. We were told over and over again in medical school that you couldn’t get addicted to a drug as long as it was taken to treat pain and that addiction was only a risk when opioids were used in the absence of pain. This turns out to be manifestly false.
As residents-in-training at a large academic medical center with its own stand-alone orthopedic specialty hospital, we have helped care for a steady stream of patients undergoing all kinds of orthopedic surgeries, with a high volume of elective total joint replacements hip and knee. Anyone who has had a total knee replacement or cared for someone who has will know that it can be an extremely painful experience.
Home staff were the first provider to be called in to address inadequate pain control. Each patient was prescribed opioid analgesics as needed. At first it was even intravenous opioids, often in the form of a patient-controlled analgesia (PCA) pump, where an opioid injection could be directed into the patient’s vein by simply pressing a button. button. How patient-centered! Anyone who wasn’t comfortable with the standard doses got a consultation for pain management, often leaving the hospital with heavy opioid prescriptions written by pain doctors.
Later in the 2010s, the medical community became increasingly aware that we were doing a disservice to our patients. The use of opioid drugs was not only a blunt instrument punishable by a fine, but opioids were wreaking havoc in communities on an epidemic scale with the rise of synthetic opioids.
Orthopedic surgeons take third place among the medical specialties in the prescription of opioid drugs. As prescribers, we have a lever to pull to affect the amount of opioids in our communities. Patients often save unused prescription painkillers “just in case.” Unfortunately, these can then be used by other members of the household or diverted to the street.
Opioids should not be a centerpiece of our arsenal of analgesic techniques. We can do better for our patients and our communities while focusing on the patient experience and the adequacy of pain control. My experience with anterior cruciate ligament (ACL) reconstruction without opioids confirmed this. It has been over a year since I prescribed opioid painkillers to a patient under 25 undergoing ACL reconstruction.. I advise all patients and their families that I will prescribe an opioid if necessary, but not a single one accepted the offer. We systematically collect pain scores on the visual analog scale (VAS) two weeks after the operation. Far from increasing, these have slightly decreased.
How do we handle this? All patients meet with the physiotherapist before surgery and within two days of surgery. They use transcutaneous electrical nerve stimulation (TENS) before and after surgery. They get a regional anesthetic block from one of our anesthesiologists, supplemented by a local injection during surgery. They use a cold machine to provide continuous cryotherapy. Standard medication prescriptions include a nonsteroidal anti-inflammatory drug (NSAID), acetaminophen, and gabapentin. A cannabinoid is also recommended. It’s cannabidiol (CBD) for our patients, without tetrahydrocannabinol (THC), the active ingredient in marijuana.
Using this multimodal approach, we have effectively eliminated opioids from ACL surgery in young people without compromising pain control. The most important intervention, however, costs nothing and has no side effects. It’s a change of mentality. The doctor’s state of mind and the patient’s state of mind. As physicians, we need to let go of the idea that opioids should be on hand “just in case”. Patients want to know that their pain will be controlled after surgery. Simply discussing it and promising to make reasonable efforts to control (not eliminate) the pain allows the patient to undergo surgery without the fear and anxiety of uncontrolled pain. Without minimizing or undermining the fact that patients’ pain can be very real and excruciating, we need to understand and communicate that the experience of pain is affected by many social, emotional and neurophysiological elements. We can help our patients choose a pain experience in which they have power that is not ceded to the pain itself or to the physician and, in doing so, do less harm to our patients and our communities.
Michael Day is an orthopedic surgeon.
Image credit: Shutterstock.com