Several authors have described the medical-school experience as “socialization” into the medical field. Medical students often learn the scientific underpinnings simultaneously with the social processes of interviewing/dialoging, examining, and then developing a treatment plan with the patient. One “subspecialty” social process that orthopaedists learn is pain management. While we are certainly encouraged to understand the scientific basis of this important and complex topic, much of the learning comes in the form of mirroring: junior residents do what senior residents instruct them to do, while senior residents follow the direction of attendings. These passed-on habits are culturally ingrained and persistent.
As Young et al. show in the July 17, 2019 issue of The Journal, the pain-management habits learned in training vary greatly from country to country, which is not surprising. Specifically, these authors examined the prescribing of postprocedural opiates by residents in the Netherlands, Haiti, and United States. They found that US residents prescribe significantly more morphine milligram equivalents (MMEs) of opioids at patient discharge than residents from either of the other 2 countries. The authors also showed that residents from the United States were the only group prescribing a significantly greater amount of MMEs to patients younger than 40 years old than to those above the age of 70.
Many pundits pin the phenomenon of opioid overprescribing in the US on the American public’s wish to be free from discomfort, along with the aggressive marketing and advertising of these medications in the United States. While this may be true, I think Young et al. have further identified the major influence that a resident’s training environment may have on prescribing practices. As already mentioned, residents often imitate what they see from more experienced residents and attendings, but sometimes those lessons, especially in pain management, lack a scientific basis.
What is missing from this survey-based study is data on patient satisfaction with postprocedural opiate prescribing. Having been involved in clinical care in Haiti, my impression is that patients there accept the local practice of pain management, constrained as it might be by resource limitations. I suspect the same is true in the United States and the Netherlands. Regardless, these findings demand that emphasis be placed on teaching orthopaedic residents evidence-based pain-management protocols. This will require a concerted effort from teachers and mentors at all levels of our medical-education system. This investigation is an important reminder that developing solutions to the opioid overprescribing problem in the US might begin in residency, where “cultural formation” occurs.
Marc Swiontkowski, MD
The current prescription-opioid/heroin epidemic in the US has been much publicized of late. According to a recent AAOS information statement, the nearly 100-percent increase in the number of narcotic pain-medication prescriptions between 2008 and 2011 corresponds to an increase in opioid diversion to nonmedical users as well as a resurgence in heroin use.
Among the strategies the AAOS statement calls for to stem the tide of opioid abuse and manage patient pain more safely and effectively are the following:
- Opioid-prescription policies at the practice level that
- set ranges for acceptable amounts and durations of opioids for various musculoskeletal conditions,
- limit opioid prescription sizes to only the amount of medication expected to be used,
- strictly limit prescriptions for extended-release opioids, and
- restrict opioid prescriptions for nonsurgical patients with chronic degenerative conditions.
- Tools (such as the opioid risk tool at MDCalc) that identify patients at risk for greater opioid use.
- Empathic communication with patients, who “use fewer opiates when they know their doctor cares about them as individuals,” according to the statement.
- An interstate tracking system that would allow surgeons and pharmacists to see all prescriptions filled in all states by a single patient.
- CME standards that require periodic physician CME on opioid safety and optimal pain management strategies.
Noting that stress, depression, and ineffective coping strategies tend to intensify a person’s experience of pain, the statement concludes that “peace of mind is the strongest pain reliever.”