Surgeons often prescribe more postoperative pain medication than their patients actually use. That’s partly because there is limited procedure-specific evidence-based data regarding optimal amounts and duration of postoperative narcotic use—and because every patient’s “relationship” with postoperative pain is unique. Nevertheless, physician prescribing plays a role in the current opioid-abuse epidemic, so any credible scientific information about postoperative narcotic usage will be helpful.
The Level I prognostic study by Grant et al. in the September 21, 2016 issue of The Journal of Bone & Joint Surgery identified factors associated with high opioid use among a prospective cohort of 72 patients (mean age 14.9 years) undergoing posterior spinal fusion for idiopathic scoliosis.
Higher weight and BMI, male sex, older age, and higher preoperative pain scores were associated with increased narcotic use after surgery. Somewhat surprisingly, the number of levels fused, number of osteotomies, in-hospital pain level, self-reported pain tolerance, and surgeon assessment of anticipated postoperative narcotic requirements were unreliable predictors of which patients would have higher postoperative narcotic use.
Because the authors found that pain scores returned to preoperative levels by postoperative week 4, they say, “further refills after this point should be considered with caution.” Additionally, after reviewing the cohort’s behavior around disposing of unused narcotic medication, the authors conclude, “We consider discussion of narcotic use and disposal to be an important component of the 1-month postoperative visit…This important educational opportunity could help decrease abuse of narcotics.”
Most studies investigating the psychosocial determinants of orthopaedic pain and disability have focused on the spine, hand, hip, and knee. But in the December 16, 2015 JBJS, Menendez et al. looked at psychosocial associations among 139 patients presenting with shoulder complaints. Similar to findings regarding those other anatomical areas, Menendez et al. found that patient variability in perceived symptom intensity and magnitude was more strongly related to psychological distress than to a specific shoulder diagnosis, which included rotator cuff tear, impingement, osteoarthritis, and frozen shoulder.
The authors measured patient pain and disability scores upon presentation using the Shoulder Pain and Disability Index (SPADI). They then analyzed the SPADI scores in relation to sociodemographic data and patient responses to three additional validated tests measuring depression, tendencies to catastrophize, and self-efficacy. They found that disabled and retired work status, higher BMI, catastrophic thinking, and lower self-efficacy (i.e., ineffective coping strategies) were associated with greater patient-reported symptom intensity and magnitude of disability.
Interestingly, BMI was the only biological influence on pain and disability scores. Also, retirement had a negative influence on pain and disability scores, which was somewhat surprising considering that retirement often has positive effects on well-being.
The authors conclude that future research focused on the effect of psychosocial factors on postoperative pain and response to treatment might “allow surgeons to identify patients who are at risk for a treatment-refractory course.” They further surmise that “interventions to decrease catastrophic thinking and to optimize self-efficacy…before shoulder surgery hold potential to ameliorate symptom intensity and the magnitude of disability.”
The connection between patient pain and clinical orthopaedic outcomes has received much attention lately. Here are relevant findings from two recent studies:
–An in-press study of 48 patients (average age of 72 years) who underwent TKA found that those with low pain thresholds prior to surgery (as measured with VAS scores while a blood-pressure cuff was inflated over the proximal forearm) were more likely to have lower Knee Society pain and function scores two years after surgery than those with moderate or high pain thresholds. The authors use this test in preoperative workups, and they advise patients who grade the cuff stimulus as severe that “their clinical outcomes are expected to be inferior to [those of] other patients,” encouraging such patients to take that into account before consenting to surgery.
–Among more than 1,100 patients (average age of 67 years) who participated in the Multicenter Osteoarthritis Study (MOST), inflammation, as evidenced by synovitis and effusion, was associated with reduced pain thresholds. However, resolution of established inflammation did not deliver a significant change in pain thresholds over two years, leading the authors to conclude that “early targeting of inflammation is a reasonable strategy to test for prevention of sensitization and…reduction of pain severity.”
Most patients with hip osteoarthritis dream of a nutritional supplement that will improve their clinical symptoms. Findings from a new study of a soybean-avocado supplement suggest they’ll have to keep dreaming. However, relative to placebo takers, those taking 300 mg a day of a proprietary soybean-avocado supplement over three years were 20% less likely to experience a loss of joint-space width of 0.5 mm or more. Alas, there were no significant differences between the two groups in important patient-centered outcomes such as pain and the use of analgesics or NSAIDs. The industry-funded study of nearly 400 patients initially set out to determine changes in joint-space narrowing (JSN) between the two groups, but researchers amended the protocol to measure progression because JSN was found not to be a “quantitative linear normally distributed parameter.”