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What role should orthopedic surgeons play in managing their patients’ persistent pain?
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Education leads to reduced narcotic consumption
In the last 15 years, we have seen a dramatic change in the national perception of pain and its management. In the early 2000s, pain was introduced as a vital sign and its under-treatment was considered an unethical and punishable act. Today, pain medications represent the second largest pharmaceutical class globally and are the most commonly abused prescription medications. As a result, the opioid epidemic has emerged on the national landscape and physicians are increasingly facing regulations on narcotic prescribing. Despite the paradigm shift, the role of the orthopedic surgeon in the management of a patient’s persistent pain has not changed, in my opinion. The orthopedic surgeon’s job is to determine whether there is an objective, musculoskeletal cause for a patient’s persisting pain. Once that cause is determined, the next goal is to initiate either nonoperative or operative treatment focused on the pain generator. In general, our training is geared toward the identification and treatment of mechanical causes of pain and dysfunction. For example, if a patient has shoulder pain, stiffness and radiographic signs of end-stage glenohumeral arthritis, the orthopedic surgeon’s role is to offer treatment options including activity modification, anti-inflammatory medication, gentle stretching, cortisone injection or joint replacement. Although narcotics play a role in acute pain management after surgery or injury, the chronic management of pain is not typically in the orthopedic surgeon’s “wheelhouse.”
As it relates to the opioid epidemic, the orthopedic surgeon’s responsibility is to minimize the use of narcotic medications in the postoperative or post-injury setting. The implementation of team-based multimodal pain management strategies can help reduce narcotic utilization and risks of addiction, but our best mechanism by which to reduce narcotic consumption is education — for the patient and for ourselves. Given that the same surgeries performed in the United States are also performed around the world, it is amazing 80% of the global opioid supply is consumed in the United States. By educating our patients regarding expectations for pain perception after surgery or injury and the dangers of narcotic medications, we allow patients to understand that pain is a normal part of the recovery process and to become active participants in the reduction of narcotic usage. By educating ourselves on new modalities and medications to alleviate pain, as well as the dangers of opioids and addiction, we can change our patterns of prescribing and tailor our patient’s expectations regarding pain management.
Surena Namdari, MD, MSc, is an associate professor of orthopedic surgery and the director of shoulder and elbow research at Rothman Institute at Thomas Jefferson University in Philadelphia.
Disclosure: Namdari reports no relevant financial disclosures.
Set patient expectations
Orthopedic trauma surgeons treat patients who have had significant injury and are at risk for acute and chronic pain. We need to educate our patients, ourselves and other providers that perioperative acute pain management is more effectively treated with nerve catheters, multimodal pain medication and narcotics. Setting patient expectations is also critical. We also need to assure patients that their discomfort is not abnormal while we observe them for untoward complications of neurovascular injury or compartment syndrome. Early treatment with an analgesic program that incorporates preoperative and postoperative multimodal options is important to avoid chronic pain, which is a predictor of poor outcomes. We need to implement evidence-based protocols to minimize patients’ anxiety, as well as acute and chronic pain.
William T. Obremskey, MD, MPH, MMHC, is a professor of orthopedic surgery and rehabilitation in the division of orthopedic trauma at Vanderbilt University Medical Center, in Nashville, Tennessee.
Disclosure: Obremskey reports no relevant financial disclosures.
Orthopedists should obtain assistance
Most orthopedic surgeons are not the best trained providers to manage chronic pain, and thus they should recognize this inability and obtain the assistance of those with more expertise in this area. It is important, however, for the orthopedic surgeon to be available and willing to assist the experienced team in the management of persistent pain. More specifically, if the persistent pain is beyond what is typical for a surgery or injury, then the orthopedic surgeon should confirm there is no anatomic or mechanical reason for the pain, such as nonunion, occult infection, pain that is hardware-related or other pathology that can be alleviated prior to the referral. Also, it is my preference to refer to a specialist who can help manage the persistent pain through non-narcotic modalities, such as non-opioid medications, nerve blocks, physical therapy and mindfulness training.
A. Alex Jahangir, MD, MMHC, is an associate professor of orthopedic surgery and rehabilitation in the division of orthopedic trauma at Vanderbilt University Medical Center in Nashville, Tennessee.
Disclosure: Jahangir reports no relevant financial disclosures.