May 24, 2016


Dr. Miller: The risks and benefits of pain control after orthopedic surgery. We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. "The Specialists with Dr. Tom Miller" is on The Scope.

Dr. Miller: Hi, I'm Dr. Tom Miller and I'm here with Dr. Thomas Higgens. He's a Professor of Orthopedic Surgery and he specializes in trauma surgery. Tom, what's new in the treatment of pain after orthopedic surgery? And I know, in particular, you deal with some very dramatic cases that come in through our emergency room and our operating rooms where you've had multiple fractures. These patients, obviously, once they're repaired, can have issues with pain control. Talk to me about that. Are there new ways of controlling their pain?

Dr. Higgens: There definitely are. Part of the challenge in trauma is that no one chooses it. It happens to you, it generally happens to you unexpectedly. And in addition to the physical pain, there are a lot of emotional issues tied to it as well. Traditionally, and when I say traditionally, I mean the last thirty years, the way that that's been addressed in medicine has been primarily with opioid pain medicine. Opioid pain medicine just means . . .

Dr. Miller: Morphine, hydrocodone, oxycodone.

Dr. Higgens: Right, Lortab, are the names that people are familiar with. And that certainly, in some settings, diminishes your pain and that's a good thing. But what has become apparent nationally and particularly in our state over the last decade is that people can enter into the treatment of their injury and exit with potentially a bigger problem on the back end with physical addiction to opiates or other side effects associated with the opiates.

Dr. Miller: And we know that nationally, the rates of overdose and death from opioid prescription medication has skyrocketed in the last 15 years. And I think that dates back to the '90s when we took up the paradigm that we should treat all pain with the most effective painkillers we had. Those happened to be opioid medications that you just mentioned. The problem is there are a side effect and a downside to that.

Dr. Higgens: That side effect really came into stark contrast when it led to mortality. I mean, the death rate nationally raised. In '03 in Utah was the first state in the nation where folks were more likely to suffer death from a prescription opioid overdose than a motor vehicle wreck. Sadly, that's the case in over half the states nationally now.

I think it's gaining attention, though, and we are lucky here at the U that we have a number of people that are studying this particular issue, men and women that are experts in these particular areas. Jeff Swinson really focuses on something called regional anesthesia. In other words, if your heel is badly injured, they will give you a nerve block, which in the three days surrounding your operation will numb the pain there. And there's nothing systemic to that. We've published papers on this that demonstrate that's a huge benefit to patients.

Dr. Miller: And doesn't result in addiction. The problem has been, as you mentioned, this high rate of overdose and death. And this must be a bit of a paradigm shift for orthopedic surgeons. The treatment of pain, typically in the past, was if you got a cast put on and you fractured your leg you got 30 Lortab. You took those home and I think a lot of people were probably using them indiscriminately and then suddenly became addicted to them.

Dr. Higgens: And that was definitely the case, but as people still had discomfort, we kept giving the medicines.

Dr. Miller: They kept coming back and asking for it, as well. We didn't want to disappoint.

Dr. Higgens: Right. Obviously, you're empathetic to folks' discomfort and you don't want to disappoint them. But the downsides, as I said, became apparent. And we also discovered that there are medicines right on our shelf already that are proven to be really effective in treating musculoskeletal pain. That is to say, pain from injury to your bones and joints.

Dr. Miller: Well, back to the regional nerve block used by your orthopedic anesthesiologist, after that block is done, do they still have pain? And if they do, are you treating that with something other than opioid prescriptions? Or did you get away from opioid prescriptions altogether?

Dr. Higgens: For some procedures in our department, they've gotten away from it entirely.

Dr. Miller: What are examples of that?

Dr. Higgens: Things like in some joint replacements, they do joint replacement completely free of opiate anesthesia under certain circumstances. That would be unthinkable 10 years ago. That's pretty neat. And some of the hand and upper extremity surgery now is done with local medicine and then anti-inflammatory medicine post-op.

Dr. Miller: Have patients accepted that or are you finding that they're coming back and not having the right kind of pain control?

Dr. Higgens: You know what I have found most interesting is that they do accept it if you tell them all about it right up front.

Dr. Miller: It's in the explanation.

Dr. Higgens: It really is. It's in setting expectations and mercifully, the population I think, now, is more aware of the opiate problem, too.

Dr. Miller: How about your trauma patients? They have, sometimes, very complicated injuries and lots of pain. Are you using different alternative modalities of pain control with them or do you use some opiates in that situation?

Dr. Higgens: We definitely use some opiates. If you have injuries to multiple limbs and/or your pelvis and/or your spine, there's really no avoiding opiate pain medicine, at least in the acute phase. But we try to tailor what we're doing to the individuals. We focus, again, on setting the expectation up front. We tell the patient now at the time of injury that they may be on opiate medicine for as long as four weeks. But four weeks is far back from what used to be the expectation in the past.

Dr. Miller: What was the expectation previously?

Dr. Higgens: Longer than that. In a paper we studied in '07, over 50% of the patients were on it longer than six weeks and 20% were on longer than 12 weeks.

Dr. Miller: Is there a relationship between the length of time they're on the opioids and the rate of addiction?

Dr. Higgens: Absolutely. And this has been borne out in the literature for quite some time.

Dr. Miller: So, Thomas, is it possible that narcotics or opioids would actually not treat pain very well? In fact, in some cases, I've heard that it can make it worse.

Dr. Higgens: There is a certain subset of the population, It's not a tiny subset. It may be as much as 20%. It can make the perception of the pain worse and after a short period of time, some patients will go from having their pain relieved to having their pain exacerbated. Ken Johnson and Dr. Light in our anesthesia department are doing research now to identify with genetic markers who those people are.

Dr. Miller: So we might even know in the future. This could be tailored pharmacologic treatment, right?

Dr. Higgens: Absolutely.

Dr. Miller: That's really interesting.

Dr. Higgens: Right now, we're not at those answers. But, for instance, there's a number of people for various issues are already taking opiate pain medicine before they suffer their trauma. And those folks have some special challenges when they come in with something that has certainly stacked another injury on top of whatever is they're already suffering from. And they are currently the ones getting the most personalized treatment, I think, because they are going to have the biggest challenge based on what's already happened to them.

Dr. Miller: Your complex trauma patients that might need narcotics, are your residents or you or the pharmacists having a conversation in the hospital with them before they leave about the need for the narcotics in order to control pain, but also the risk and what they should be aware of? It seems like educating the patient on what the potential downsides of the treatment could be would be helpful.

Dr. Higgens: We actually did a study on this that we published, I think, about four years ago. We had a group that were counseled and a group that were not counseled. The group that were counseled got off all their narcotics by six weeks at a much higher rate. Counseling can be variously defined, but for us, today, it is for myself, for my partner, Dave Rothberg, when the patient comes in injured we tell them and their family at the time, "This is our expectation going forward. We are going to make sure we get your pain controlled, but we are going to make sure we have an exit strategy from the opiate pain medicine."

Dr. Miller: So the notification to our patients who are listening to this is don't always expect that you are going to receive narcotics or opioids for pain control after surgery, that there are new modalities that are not addictive that they would potentially save your life compared to older treatment.

Dr. Higgens: Absolutely.

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