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9 Articles in Volume 15, Issue #5
Case History of Chronic Migraine: Update 2015
Chronic Pain Patients Who Fail Standard Treatment: Now What?
Diagnosing Fibromyalgia
Gabapentin Abuse
Microglial Modulators: A New Therapeutic Class
Myofascial Pain: What is the Best Treatment?
Pain and Aging
Spirituality & Healing Touch
Tables Turn on Pain Psychologist

Tables Turn on Pain Psychologist

When faced with a rotator cuff injury, Dr. Passik experiences first-hand how pain management is delivered in a busy orthopedic practice.

They reassured me several times going in that my pain would be well treated.

Actually, they weren’t simply being reassuring—they were almost bragging. It was as if they were saying, “We are showing you our humanity.” My orthopedic surgeon’s staff was happy to let me know that I would have ample access to pain medications, including opioids, as needed.

The tables had certainly turned on me. After a 25-year career as an academic psychologist whose clinical and research focus was on cancer and non-cancer pain management and their interface with drug abuse, I found myself being evaluated for shoulder surgery. I was none too happy about it. I had seen many patients who had undergone rotator cuff repairs and I knew it to be a difficult procedure with a long and painful rehabilitation.

After a bad slip and fall on the ice in downtown Indianapolis on Valentine’s Day, 2014, and a resulting complete tear in 2 tendons in my rotator cuff, I had passed the 3-month mark of having severe, episodic pain in my shoulder. With the exception of occasional doses of ibuprofen, I hadn’t sought any treatment. On a recent business trip, a colleague and friend noticed I was grimacing when I moved. The colleague asked me what had happened and then asked if I was nuts. Was I going to get it looked at and treated or was I hoping for a shoulder replacement?

In just a short while I found myself waiting for an MRI. But it wasn’t just the possibility of permanent damage and the need for an even bigger surgery that finally moved me along the trajectory to patient-hood. It had been amazing for me to learn on a personal level how even a very specific pain that only comes on with certain movements can make you feel so unwell. It had been particularly bad for me at night. I’d wake unrested and feel bad enough in the morning that I would skip the visit to the gym. I gained a lot of weight; I felt fat and old and depressed. I couldn’t let this vicious cycle continue.

Meeting My Treatment Team

So I finally got myself in to see an orthopedic surgeon. I met him, his fellow, and several members of the staff. All were extremely professional and friendly. While it was in these meetings that the availability of pain medication was mentioned, the topic of conversation was mainly my shoulder. As expected, I was not asked much about myself nor what I do for a living. Most importantly—and this is typical and not a mark against this very professional group—I was never asked about a history of risk factors for addiction. Nor were any questions asked about previous experiences with opioid pain medications.

So here comes the part where those of you who have been barraged with reports about how “powerful and addictive” these medicines are expect me to reveal that I was a former addict, and due to the exposure to opioids post-operatively, my disease was rekindled and that I am writing this from rehab to warn you all about the dangers of prescription drugs.

Spoiler alert: I am not a recovering addict and that’s not what happened at all.

I received state-of-the-art pain management. I had multimodal drug and interventional therapies and my pain was exceedingly well-managed. Nine months further down the road, my shoulder is as good as new. Every aspect of my treatment, I believe, was up to or exceeded the standard of care. In a way, though, that’s also the sad part. The standard of care does not include screening questions about addiction.

Standard of Care or Substandard Screening?

We all know that opioids are the cornerstone of the management of moderate-to-severe acute post-operative pain. However, in many cases, pain after shoulder surgery can continue to be moderate to severe for 3 months, requiring opioids for much of this time. A 3-month exposure is not trivial to a person at risk for addiction.

I traded in my opioids for regular bowel movements after 6 weeks. By then, my need for them had been decreasing, apart from sometimes after physical therapy (PT) sessions, and regularity was worth more to me than a couple of hours of relief (and topical diclofenac was doing the job after PT sessions in any case).

Does the standard of care amount to relying on dumb luck that everyone will follow this same uneventful course? My story is banal. Hundreds of thousands of knees and shoulders, and other assorted bones and body parts, are being operated on all the time. Unfortunately, opioids are prescribed without detailed addiction risk assessment in perhaps the majority of cases.

I asked my friend, Ian Carroll, MD, from Stanford to read and comment on this piece when it was in draft form. His research focuses on describing the different trajectories of opioid use post-surgery. He replied, “I’ve come to feel the first prescription should be given rather easily and the second should be very hard to get. I think there is still a very low appreciation for the role of surgery in the genesis of new chronic pain and new chronic opioid use.”

He also commented on something that I wondered about myself: suppose I did have risk factors for addiction and was in anything but the lowest risk group for complex post-operative opioid use. Would anyone on the team know strategies to employ to act on that realization? Ian went on, “I think if you had been the highest-risk individual, we still don’t have a clear pathway for alternative (post-operative pain) treatment—physician-guided wean? Previously agreed upon commitment to a set stop date? Early referral to an addiction medicine practitioner for secondary prophylaxis?”

This is a particularly complex set of questions in orthopedic procedures in particular, since many orthopedic surgeons would like to avoid the most likely alternative to opioids—non-steroidal anti-inflammatory drugs—for fear that they inhibit bone and ligament healing based on evidence provided by studies done on animals.

I would add one more wrinkle from my clinical experience: poorly treated, unrelieved moderate to severe pain could serve as a risk factor for relapsed drug abuse in people with a history of addiction if these issues are managed by simply avoiding opioid medications without a more elaborate plan for relief of their pain.

Now I would like to give the treatment team more credit than I appear to be giving—I mean, they perform many of these procedures every year. If I had looked at a patient like me and I wasn’t a mental health professional, I might have thought most gray-haired, pudgy, middle aged, nerdy looking psychologists from my zip code are not drug addicts or dealers. And in my case, I would have been right.

The medical literature is replete with admonitions and demonstrations that this sort of clinical flying-by-the-seat-of-your-pants is not how these judgments are to be made. There are known risk factors for the abuse of pain medications and they include:

  • Younger age
  • Male gender
  • Personal or family history of drug abuse
  • Active psychiatric comorbidities
  • History of preadolescent sexual trauma
  • Cigarette smoking

These risk factors must be assessed and then if present, management of pain must be altered to be commensurate with a person’s level of risk. Opioids might not—and should not—be avoidable in many cases and, while as Ian pointed out, what to do remains unclear, a substance abuse expert could be included on the team to help manage them and make sure there is no loss of control.

So the mere fact that I am gray-haired did give the team some latitude and this is also what saves oncologists from running into more trouble than they do. Oncologists also prescribe controlled substances to patients without much of an addiction risk assessment; and many of these patients living with and after cancer are no longer subject to only abbreviated exposures to opioids as they live longer and longer—some with chronic post-treatment pain syndromes.

Pain Management 101: Risk Assessment

Newsflash from Addiction Medicine 101: 85% of addictions are present by the age of 35.

So when a 55-year-old comes in for surgery, or you are treating a disease like cancer that is still primarily a disease of the sixth, seventh and eighth decade of life, there are some built-in safeguards. And, yes, this does mean that the very same pain management protocol I received is inherently riskier in the newly injured high school quarterback than it is in someone like me, who has had the sobering realization of midlife that he will probably never be an NFL star.

The assessment, however, doesn’t end with age nor is age alone a perfect predictor. We must raise the standard of care and teach every practitioner how to conduct the assessment and recognize when higher-risk measures are necessary. For every thousand post-operative cases that go well, there may be one young life ruined by addiction—a tragic occurrence that lends fodder for a media black eye for the field.

As we all know, opioid prescribing has increased dramatically in the last several years. Some patients have benefited greatly, while others have been seriously harmed. There are risks and benefits of opioids in the treatment of acute and chronic pain that can be balanced with time, expertise, and the use of the tools and strategies that have emerged over the past few turbulent years.

What people who are suffering with pain need is neither a blank check for opioids nor a complete avoidance of them on the part of their providers. Humanity is not demonstrated by the willingness to provide opioids nor is it shown by being overzealous about protecting people from opioids; humanity is demonstrated by maximizing what can be done to help, while minimizing harm to those who suffer. We owe it to the suffering people who seek our help for pain to be thoughtful, careful, educated and open-minded. If we are all of these things, our humanity will be obvious.

Last updated on: May 25, 2017
Continue Reading:
What are some home exercises and tips to help patients manage rotator cuff injuries and pain?

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