Good findings and bad conclusions on post-op pain treatment

Today’s “egg in your face” article from the American Academy of Orthopaedic Surgeons (via Science Daily) says:
One out of five adult orthopaedic trauma patients sought additional providers for narcotic prescriptions

http://www.sciencedaily.com/releases/2014/08/140811125114.htm

Link to the original JBJS article: http://jbjs.org/content/96/15/1257.long

Overview

Sadly, the orthopedic industry is still blaming the patients:

“Many suspect that orthopaedic trauma patients may be at a higher risk for pre-injury narcotic use and ‘doctor shopping.’”

The underlying accusation of addiction in that prejudicial statement is wholly unsupported in the information provided.

Moreover, that prejudicial opening statement opposes their own findings about the psychosocial context of these people:

“The “doctor shopping” patients had an average age of 39.6 ±12.2 years, and were primarily white (89 percent) and male (63 percent). Forty-four percent were uninsured. There were no differences between the single-provider and multiple-provider groups with regard to age, sex, race, injury type, distance between the patient’s home and treating hospital, tobacco use, psychiatric history (depression, anxiety, attention deficit hyperactivity disorder, or bipolar disorder), or comorbidities.

[Emphasis mine.]

Findings vs. conclusions

Let’s address these points in order:

  1. Men handle pain worse than women. They’re not well-designed that way. White men of mature years feel entitled to be treated. (Note that people of color are more likely to avoid conventional care, for good historical reasons. Women feel greater pain for the same injury, but are used to being undertreated and ignored, also for good historical reasons.) If adult white men are restricted by pain, they’re going to get pain meds, because they must function, and they cannot function past a certain limit of pain.
  2. The uninsured (who were counted) and underinsured (who weren’t) who’ve had a recent trauma requiring hospitalization are going to be under geometrically more stress than they were before: issues of money, mortality, and function can be overwhelming; work may be hard or impossible because of the injury, so ongoing survival is at risk; and recovery may be threatened because of the interplay of stress, undertreatment, and lack of rehabilitative care due to insurance and financial issues… all of which exacerbate post-operative issues and grind in stress levels. Any guesses about what significantly higher stress levels do to pain and pain tolerance over time, not to mention healing speed and nutritional needs? Right. More pain meds are needed.
  3. Most importantly, there are NO CORRELATIONS with the biggest addiction of our age, tobacco, nor with psychiatric history or logistical issues; these folks aren’t out for an easy fix, they’re doing what it takes to get what they need. (It’s important to reiterate that these scientists discovered those points themselves, but ignored them.)

This last issue, alone, is a big fat hairy clue that postoperative orthopedic pain is undertreated nearly 20% of the time — not that 20% of these ordinary folks are suddenly mainlining narcotics or flogging them for a few bucks a tab.

Two more points deserve critical attention:

Patients with a high school education or less were 3.2 times more likely to seek multiple providers (p = 0.02), and patients with a history of preoperative narcotic use were 4.5 times more likely to seek multiple providers (p < 0.001).

People with higher education have better command of information, can generally get their hands on better nutrition, and can more easily seek modes of self-care other than, and in addition to, conventional medicine. Assuming that, just because people are poorly educated, they must be seeking drugs for recreational use rather than because they don’t have access to good alternatives for pain management (including less physically demanding work), is a straw-man argument with contemptibly classist roots. I suspect I’m a lot closer to a lot more poorly educated people, and have made a much closer study of the data around their decision-making processes, than these orthopedic surgeons.

As for the second point in that quote, there was no assessment as to why people were taking narcotics pre-injury, and the assumption that doing so is necessarily wrong is blatantly daft.

People who are already being treated for pain, and then go through something as brutal as orthopedic surgery, know full well what’s going to happen if they ask one doctor for all the pain control medication that they need. Because their physiologic margins are already being stressed, it is perfectly reasonable to expect their medication rates to be higher, but the guidelines for narcotic administration don’t allow for that outside of late-stage cancer treatment, because cancer patients are presumed innocent where other pain patients are not.

Moreover, people who live with pain tend to have a harder time moving and are physically slower to react, so they are more likely to get injured. I speak from bitter experience. It doesn’t mean the pre-op narcotic use is inappropriate, but instead follows logically from the nature of living in pain.

The echoing silence on that issue alone pollutes all the rest of the study.

Consider the source

This prejudicial article would need to look elsewhere for data to support the idea that ~1/12th of pre-op and 1/5th of post-op orthopedic patients are users or pushers or both, but it consummately fails to do so.

As a sometime RN in homecare and emergency care, as well as a longtime pain patient with an orthopedic-surgery-triggered iatrogenic disease and a wide network, I find it far more believable that orthopedic pain is hideously undertreated. On top of the usual issues around invisible problems and pain conditions, orthopedic surgeons really don’t get it about how deep and hard that pain is.

They trivialize pain and recovery time because they don’t see the patient through to 100% recovery, only to the point where they aren’t likely to have acute complications. Thus, they really don’t understand the impact it has on real life. Far too few orthopedic surgeons have undergone major injuries, let alone orthopedic surgery, and fewer still have had complicated recoveries.

Basically, in orthopedics, the blind are treating the lame.

The real issue: narcotic abuse is on the rise

I’m not dismissing the anxiety in the article. Diverting narcotics is a real problem with ghastly consequences, including a tragic death toll and wholesale disruption of families and communities. Dealing with that as an addiction issue from a public health standpoint and a community-engaged model is the useful approach. Demonizing patients is not.

The useful approach requires social spending, which is currently unfashionable despite the rate of savings (~$1:$3 to ~$1:$1000 annually, depending on issue being addressed, depth and efficiency) which it provides. Demonizing patients comes for free, but the downstream costs in health, productivity, long-term care, and ultimately police and court costs, is horrific, but rarely calculated.

It’s indefensible to continue to condemn patients to needless pain and debility, the misery and humiliation that accompanies it, and the outstandingly hateful and contemptuous treatment they get from “care” providers if they’re suspected of being drug seekers.

Repeating: I was an ER nurse; I get it about drug seekers. Criminalizing pain patients does not address that issue.

Related issue: addiction does not bar treatment

In my view, it is never acceptable to withhold appropriate treatment. People with addictions may develop pain syndromes; this doesn’t mean they shouldn’t be treated with them. It requires more and better communication from both doctor and patient, and the patient’s physical needs have to be met within the context of their behavioral needs.

If I were treating someone with addiction and pain, and found that narcotics were the best option for handling the pain, then yes, there’d be more monitoring, because that’s a practical form of support for their sobriety. Focused counseling and CBT would be appropriate, because they may need help with redefining sobriety to mean, “taking meds as prescribed,” especially as that involves the sobriety skills of honest information communication with care providers — a big step.

The current fashion for dehumanizing addicts is predictable, given the divide-confuse-and-suborn political environment, but it remains utterly unethical. The road to sobriety must be a feasible challenge before anyone can be expected to rise to it. This does not mean abandoning them with untreated or under-treated pain.

Outcomes

When the scientific establishment ignores its own findings to perseverate on an outdated, counterproductive, fiscally and intellectually indefensible meme that penalizes and further harms patients, nothing improves.

This is a problem — and because legislators and the public tend to listen to these organizations, in defiance of the hard data and common sense, it’s one that breeds lots of other problems, each one as unattractive, expensive, and useless as its parent.

Clinical takeaways

It’s important to distinguish between real needs and artificial worries. The clinical takeaways are threefold, in order to take that into account:

  • Orthopedic pain is undertreated roughly 1/5 of the time. Current treatment parameters do not account for a significant proportion of outliers, and should be used with appropriate flexibility.
  • Postoperative treatment is more problematic than ever. With nearly half the population still uninsured and many of the rest underinsured, and simultaneously pain treatment being examined more narrowly every day, then recovery, rehabilitation, and patient education around these issues is more important than ever. Every patient should go home with printed, illustrated aftercare instructions which include the following:
    • Expected timeline for stages of recovery to 100%, with instructions on how to track and record stages, and what to do for complications or setbacks before, up to, and including calling the doctor. No surprises, unless both you and your patient are surprised.
    • General, practical, ADL and work-task focused guidelines for gradually progressed activity, day by day or week by week as appropriate, until 100% recovery is expected — with instructions on how to handle variances and setbacks. No surprises, unless both you and your patient are surprised. These should ideally be written jointly by orthopedists, occupational therapists and physiotherapists.
    • Nutritional guidelines for healing. These are absolutely basic but doctors, especially surgeons, consider it beneath them. A bit like breathing is beneath them, really. Let’s focus on the facts, and the fact is that vitamins and minerals in appropriate forms and quantities yield enormous benefits (vitamin C, 500 mg BID, prevents 80% of CRPS conversions, for instance) and deficiencies in calcium, magnesium, phosphorus, B vitamins, D vitamins, protein, EFAs and antioxidants result in more complications, slower bone and soft-tissue healing, and greater post-op needs.

    Posting those instructions online in generic form, perhaps under a Creative Commons license to facilitate collaboration, could be very useful to countless patients and care providers. If you have such instructions online, please post a link to them in the comments here and share them wherever appropriate. People need that.

  • The data from the American Academy of Orthopaedic Surgeons seems good, but their stated findings are highly political, not logical or practical. Go to the data and use your own intelligence to draw conclusions, because politics change but the principles of good practice do not. We all need to be reminded of that periodically…

Postscript

Highly attentive readers will notice that the study mentioned no correlation with comorbidities. I can’t access the full text of the study, and in the outer material, there was no description of what they considered comorbid. It might imply prior illnesses or conditions, or it might not. Given the gaping holes in the work otherwise, it doesn’t make sense to weight this statement at all. There is no indication, on the basis of the available information, that prior pain or musculoskeletal issues were assessed or accounted for at all.

Links

Science Daily article, with quotes from the study authors: One out of five adult orthopaedic trauma patients sought additional providers for narcotic prescriptions

JBJS posting of the study’s outer material (full article only available with subscription; this free material is what the authors chose to show): Narcotic Use and Postoperative Doctor Shopping in the Orthopaedic Trauma Population

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Suicide, including veteran suicide, handled back to front

This article discusses suicide among returning veterans:

Suicide Prevention Expert Outlines New Steps to Tackle Military Suicide

The up-side is, it brings more attention to this national shame: “..while only 1% of Americans serve in the military, the suicide rate of veterans accounts for [20 %] of the overall total in the US.” [Emphasis mine.] They’re overrepresented in suicidal despair, even at this time of epic national meltdown, at a rate of 19:1.

There are some good ideas (badly put) under this deceptive title (new? Hardly), with an unfortunate insularity and gee-whizz ignorance in parts:  “the effects on the mental health of active-duty service members, reservists, and veterans is only just beginning to be felt.”

Only just beginning to be felt? By whom? Reports started streaming out of this population from the start!

The horrific rate of PTSD, brain injury and subsequent/consequent suicide among modern veterans has been in the news nearly since the Iraq war started. And the effects were “felt” by affected veterans and those who love them from the beginning.

That was an astoundingly insensitive choice of words, and when a social scientist is astoundingly insensitive, it automatically makes me question his insight and judgement. After all, social scientists have to pay attention to social cues and have some social awareness in order to do their jobs well.

The suggestions made by this article are,

  • Reduce access to guns and other means of suicide.
  • Watch for sleep disturbances. 
  • Prescribe opioid medications carefully and monitor.
  • Improve primary care treatment for depression.

These instructions are useful and appropriate (though not new at all), but the order puts the primary burden in the wrong place.

The reflex is to consider first how to change the patient’s context and control, and second how to change the provider’s context and control.

But which person — doctor or patient — do the policy makers have more access to?

Which has broader (and more cost-effective) reach per person?

Where does influence and support really come from — especially when the patients themselves are desperate and don’t have the resources to face what they’re dealing with?

Hint: Only one of these two people is licensed, monitored — and paid to show up.

It might be time to focus first on how to change the provider’s context and control — in this case, train primary care physicians in how to evaluate for mental health issues without losing their own minds, and make it easier for them to be more mindful, conscientious and appropriate when prescribing CNS depressants such as opioids.

Policies regarding these things may need to be updated. Despite some alterations and improvements, they still focus on controlling the patient’s access to meds and autonomy, rather than on changing the provider’s involvement and awareness of what’s going on.

This is exactly back-to-front.

This is the best we can do??

At-risk patients — those with PTSD, intrusive pain, or some other confounding factor — need to be seen more often and have mental health screens at each visit. Since many of the well-tested screening tools are short checkbox quizzes, that’s a reasonable addition to care. Some can be filled out in the lobby by the patient.

This serves several purposes: the frequent care provides a disproportionate feeling of support to the patients, reducing despair and helplessness; if the visits feel excessive, it motivates the patients to improve their own resources and self-care, reducing passivity, which improves outcomes; and bad findings on the quizzes provide quantifiable, documented need for mental health care, which can then be provided in a more timely manner and with less argument from payors.

Speaking as someone with significant confounding factors (chronic pain, neuro dysregulation, and acute life stress) I’d be delighted to know my doctor and health care system would do that for me, even though I’m not remotely suicidal myself.

When the behavior of those who are easiest for policies to reach AND most influential in patient care is more appropriate and effective, then it makes more sense to go to the trouble and expense to reach further out into the population’s private lives and try to manage them there.

A more rational and effective approach might be,

    1. Train and retrain all primary care doctors to look for mental health issues. This is something that suicide prevention specialists have been screaming for for years. It’s mentioned last in this article, but should be mentioned first: people who commit suicide were likely to have seen their doctors within a month. Talk about a cry for help falling on deaf ears!

      But most doctors turn into deer in the headlights in the face of mental distress, because they have no real idea about what to do. There need to be better guidelines, a clearer path to mental health follow-up, and failure to meet basic requirements of care needs to create problems for the provider — as they inevitably do for the patient.
       

    2. Manage access to obvious methods of suicide, like CNS depressants and firearms. There are many profoundly depressed people who will kill themselves if it’s easy, but fewer who will really put a lot of energy into it, because energy plummets with major depression — along with impulse control. A deadly combination.

      Reducing access involves having primary doctors get more involved with patients who get CNS depressants like opioids and benzodiazepines; implementing and enforcing access laws to firearms and ammunition; and noticing at-risk people with drug and firearm access and giving them the training they need to reduce their own access on an impulsive basis. (Yes,that’s right, engage the patient’s own inner and outer resources, rather than simply impose limits outside their control.)
       

    3. Increase time span between impulse and action, giving second thoughts a chance to kick in. This is important, because the despair is stubborn, but the suicidal impulse comes and goes. Give it a chance to go, so the person has a future and a chance to recover.

      This involves, again, noticing them; engaging them to leverage their own capacity for self-management; and getting logistical support from those around them.
       

    4. Look for early signs, like sleep disturbance, mood swings and eating or weight disturbances. Don’t know why the latter signs aren’t even mentioned here, when they’re easier to notice from the outside. Veterans certainly have them.

      We’ve been pushing for effective education for all primary doctors around both mental health and pain control (which are tightly linked) for decades. It’s not new, it’s just ignored, underfunded, and badly implemented, costing billions in direct and indirect costs.

      Mental health and pain control are tightly linked because:

      • Pain is depressing.
      • Pain is limiting.
      • The helplessness of those limitations is depressing.
      • CNS depressants are, literally, depressing.
      • Depression and helplessness significantly increase pain response in the brain and nerves.
      • And back around we go.

      It’s a vicious cycle, keeping overtaxed minds between frying pan and fire…

      Lasting treatment success is tied to increasing someone’s sense of self-governance and engagement with life (reducing actual helplessness) not limiting their options and patronizing them into submission (increasing actual helplessness.)

      [Limiting options is necessary and useful for inpatient treatment, but is highly problematic in outpatient care — which is where most mental health issues take place.]

      That same engagement and sense of self-governance also reduces the neural system’s susceptibility to pain.

      It breaks the cycle.

      One of these people is not engaged in life. The other is. Which seems better?

      Let’s do all that now — at last — and see how much faster the suicide rates drop than at any prior point in history. For veterans, civilians, everyone.

      It’d be cheap, effective, and useful. It’d serve our veterans and increase productivity. It’d brighten up the lives of everyone affected by it. Is there a downside?

      Links:

      Suicide Prevention Expert Outlines New Steps to Tackle Military Suicide. ScienceDaily (Sep. 10, 2012)
      6,500 US Military Veterans Commit Suicide Every Year, International Business Times (April 2012).
      Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. NEJM (July 2004)
      PubMed search for “PTSD veterans” results.
      PubMed search for “TBI veterans” results. TBI stands for Traumatic Brain Injury.
      Make the Connection, bringing generations of vets together for mutual support and counseling.
      Suicides — United States, 1999–2007 Centers for Disease Control (January 2011).

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