I was so excited the other day when the package finally arrived at my doorstep. I had ordered it months ago and was expecting a really large box filled with the latest in fantastic gadgetry. I love gadgets probably like no other person but when they can give me a leg up on clinical management, this love escalates to a level that would render most folks to sedatives and restraints.
This was the deal that would help me solve so many of those pesky clinical details, like how I really measure this nebulous beast we face routinely. Needless to say, disappointment of a deep aching nature still echoes in the hollowness of my clinical conscience now that I realize I have been duped to the extreme by this unscrupulous company purporting to have the ultimate, most up to date measurement device for the quantification of the monster we and our patients must face daily.
I will not even begin to tell you how much I have yearned for such technology. Now that this technology has all disappeared in the quick vapor of seeing the thin envelope laying there on the mud stained door mat, indescribable anguish (no pain) has rendered me to a small corner in a dark room, rocking back and forth inconsolably in a fetal position, staring at the envelope.
Who is this beast we face daily? Why are we so afraid of it? Why can’t we stand up for ourselves and fight it more effectively? These are complicated and tough questions that may never be fully answered but for the sake of a blog, let me try.
The beast, as you know, is pain. It is not that pain when you bend back your dominant thumbnail and break the nail halfway back with bleeding and all that stuff trying to get the hose attached to the tourniquet. (That really happened just this week. I could never come up with that analogy without some real-life experience.) Even though my mangled thumb could detect air mass movement in the adjacent state, this is not the type of pain I am referring to here.
I am talking about nociceptive chronic pain. While we are at it, let us talk about acute pain, especially postoperative pain. We know that if we do not adequately treat the acute, we can end up facing the much more daunting chronic pain.
There are many unfortunate patients out there who deal with this nasty unrelenting beast, because we are either being crippled by our inability to fight with all our weapons or we are not willing to. Maybe it is both. Many are scared by the Drug Enforcement Agency and other G-men threatening the practitioner for the over prescribing of medications, especially opioids.
Other practitioners just label a patient as an “abuser” or “drug seeker” if he or she asks for a specific painkiller or tells you the one you prescribed is not working. “Hey, Dude, that is some powerful stuff I gave you for pain,” you want to yell back at the patient defensively.
What if the patient is simply one of those 10 percent of our population who does not manifest the cytochrome P450 2D6 enzyme, which metabolizes the prodrug (for example, codeine) into the active one (morphine)? Are these people then “seekers” or “abusers”? I think not. They are just DNA challenged. But how many of us can know that except by history taking and a belief that what the patient is telling you is true?
Well, there are now tools available that are going to become very popular in the near future to give us the ability to find the “CYP450 2D6er challenged.” Then we can more appropriately prescribe for that patient. How? Just take a swab and wipe their buccal mucosa, mail it in and wait 48 hours. You will have your answer. In those fancy Ivory Towers of Academia, they call that Pharmacogenomics.
Now we need to discuss some facts about pain and outpatient surgery. I know you will find these facts titillating and perhaps even more enrapturing than finding out what is in my envelope.
Here are some salient excerpts from “Post-operative Pain Experience: Results from a National Survey Suggest Postoperative Pain Continues to be Undermanaged” by Apfelbaum and colleagues in the journal Anesthesia and Analgesia.1
• 73 million surgeries are performed annually
• 75 percent of patients experience pain after surgery (I hear some readers saying to themselves: “Well, that’s a no brainer, Bob—I just cut her bone.”)
• Approximately 70 percent of all surgeries in the U.S. now occur in an ambulatory setting.
• Negative clinical outcomes resulting from ineffective postoperative pain management include deep vein thrombosis, pulmonary embolism, coronary ischemia, myocardial infarction, pneumonia, poor wound healing, insomnia and demoralization.
Wow, now that is eye opening! Are you telling me that my surgical outcome can be jeopardized by poor pain management in the postoperative period?
Now here is a real axon kicker.
• It is estimated that the economic burden of treating chronic pain that develops from acute pain in a 30-year-old individual over a lifetime could be as much as $1 million.
Groups like the Joint Commission are taking this stuff seriously now and have been since 2001 when it mandated that pain management must be part of all patient care in hospitals in order for hospitals to maintain accreditation. What this means is that over the career of anyone who does even a modicum of surgery, there will be those unfortunate few who develop chronic nociceptive pain from acute surgical pain and they are going to cost us (the taxpayers) a few million bucks.
What can we do to prevent or preempt the possibility or probability of having one of our “acutes” becoming “chronic”? Here are a few of my suggestions.
1. Get to know the patient preoperatively and try to gain a sense of his or her psychology about pain.
2. Explain the procedure and tell patients all that you are going to do to help them avoid pain. Be empathetic and friendly. Researchers have proven that this lowers pain in the post-anesthesia care unit (PACU).1
3. Use preemptive blocks on every surgical procedure, even if it is just minor. I do this even with general anesthesia, which I use on almost all of my cases. Keep the stimulus from getting to the spinal cord.
4. Minimize dissection. When there is less tissue destruction, there is less pain. That is a fact.
5. Place long-lasting local anesthesia in the surgical sites at the end of the case.
6. Use some dexamethasone phosphate when possible and not contraindicated.
7. Have the anesthesiologist give them some ketorolac, which is proven to reduce postoperative demands in the PACU for opioids.1
8. Put the dressing on with just the right amount of compression. If patients call that night in pain, tell them to cut the bandage. What a difference this will make for some of them. Some patients just swell if they say their pain meds are not working—believe them. Change the prescription or increase the dose. Remember, they may be those patients who lack the enzyme.
9. Do not hesitate to give the patient a peripheral nerve block on post-op day one if he or she is having an inordinate amount of pain.
10. Take some time post-op if you have a patient with pain out of proportion to the procedure to see if there is something else going on (i.e. family problems, etc.). It would have been nice to know these things before going in to the surgery but then there is reality.
Most of the time, our patients come in telling us how much pain they were expecting and how they really did not have any. This is a good thing.
Now let us open that envelope and see what I just got from that company I was referring to earlier. It was just some sheets of paper for a visual analogue scale with sad to happy faces on it to measure pain. Yeah, that’s right. Sheets of damn paper.
The fact is, with all our technology, we don’t really have any way to objectively measure pain or quantify it. The mythical “pain-o-meter” just has not made it into production yet. When it does, I am getting one.
1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003; 97(2):534-540.