Surgical Pain Should, and Could Be, Managed Better

I wanted to spend a moment talking about the opioid crisis from a physician prescriber perspective. There are many types of pain, pain in our muscles and bones, what we call somatic pain; and pain in our organs, those ‘tummy’ pains we call visceral pains. I would suspect that most of the pain medications physicians prescribe are for those somatic pains. There is another distinction regarding pain that frequently gets overlooked in the heated opioid crisis, some pain is acute, from the moment of injury, and some pain is more chronic a result of the injury but later on. As a surgeon, my skill set resulted in inflicting acute pain, surgical pain and I want to spend a few minutes talking about how it might be treated to lessen the risk of ‘opioid dependence’ at least from surgical care. I would offer up two principles.

• Pain management should be preemptive
• Pain management should be patient controlled

By preemptive I mean that we should be starting pain medications before the pain becomes clinically significant to the patient. You can find a primer about the concept here. The problem with our traditional approach is that patients have to wait for the pain to get to the point where they ask the nurse for medication. Even when the surgical floor is not busy that can mean an additional 15-minute wait to get medication and often another 15 minutes before the medicine takes effect.  Hospitals know this, and most hospitals now ask their nurses to be preemptive and check on patient pain level every few hours. When a physician writes a prescription, there are instructions for how often to take the medication, based on the medicine’s time of onset and duration of therapy. But no two of us are alike, so onset and duration will naturally vary.

There are a variety of other techniques that can help us achieve the goal of preemptive care. The simplest one that I know is to inject a long-acting local anesthetic in the wound, as the surgeon is closing it. For many years, physicians had limited choices in this regard. Local anesthesia, like the injection your dentist gives you when they fill a cavity, last for 45 -60 minutes. There are more other anesthetics that last for four to six hours, and while that is a step in the right direction, it certainly is not sufficient to manage surgical pain from an incision.

In the last few years, pharmaceutical companies have reformulated this longer acting local anesthetics with a different carrier, which allows them to be released over 48 to 72 hours - sufficient time to control the acute pain following surgery. For nearly the last two years of my practice, I put this type of agent in my patients’ surgical wounds. And while it is anecdotal, observational data, my patients rarely needed narcotics [1] and went home typically a day earlier than our national averages.

(For a look at the chemistry of how longer-lasting local anesthetics work, see the companion piece by my colleague Josh Bloom here).

Another technique is to provide a block the response of the nerves supplying the area of incisions, against using local anesthetics (nerve blocks). There is a growing literature on the benefits of these anesthetic approaches regarding promoting patient satisfaction and reducing the length of stay. The problem is that they take some time to place, and surgeons are not always the most patient of people (ask my family or surgical team) and sometimes the block just doesn’t work well.

Pain has many manifestations, but one we rarely discuss but that is of great concern to many of our patients is, loss of control. Something hurts, and there is little you can do to help yourself. Patient-controlled analgesia (PCA) is another technique physicians can use, at least for their hospitalized patients. With PCA, you can give yourself an intravenous (therefore fast acting) dose of opioids whenever you need it. Let me hasten to add that your physician controls both the dosage and the time interval. But being able to press a button every 10 minutes to get a small dose of pain medicine is again more effective and satisfactory than calling the nurse. The control returns to the patient.

PCA, nerve blocks, local anesthetics are part of a variety of techniques called multi-modality pain management. (Don’t you love the terms we create?) They are effective for patients resulting in a longer pain-free interval which in turn increases patient’s mobility and reducing the time you have to spend in the hospital or rummaging around your house for your pill bottle. Why aren’t hospital-based physicians making an effort to bring these techniques to our patients as the standard, rather than the exception? The difficulty lies in education, in coordinating care and shifting a very old prescription culture. Changing the status quo is hard and unsettling. As physicians, we have an opportunity and should remember the words of Rahm Emanuel, “You never let a serious crisis go to waste. And what I mean by that it's an opportunity to do things you think you could not do before.”

[1] By rarely I mean perhaps 2-5% of the time.