Pain Management 

The United States consumes 99 percent of the world’s narcotic supply, and this consumption continues to accelerate. No compelling reasons exist for this significant volume increase. In 2011, 50 million Americans were prescribed some type of narcotic pain medication, which was nearly double the number from 2008. In 1990, 627,000 people used narcotics recreationally for the first time. By 2005, that number tripled to 2.2 million recreational drug users. Overdose is now the #1 cause of death in the US in young adults ages 25-45. Interestingly, most pain medication abusers don’t get the pills from dealers, but from friends, relatives, and physicians. The implication is that physicians are prescribing excessive amounts when dispensing pain medications. Physicians are caught between the need to help control pain and the risk of over-prescribing narcotics. Studies show that increasing narcotic dosages do not necessarily correlate with pain relief and patient satisfaction. Factors that predict higher use of narcotics include anxiety, depression, smoking, and previous narcotics use. Fracture severity and number of fractures does not accurately predict a patient’s heavy use of post-operative narcotics. The Drug Enforcement Agency (DEA) recently emphasized that “a prescription must be issued for a legitimate medical purpose by a registered physician acting with the usual course of professional practice.” The courts have indicated the following red flags that may indicate illegitimate use: inordinate quantities, inconsistent intervals, no physical exam, refills in patients suspected of selling medications, use of street slang (eg, “Oxys” “Hydros” “Vikes”), no logical relationship to the underlying condition.

Representatives of the American Academy of Orthopaedic Surgeons have recommended that any evidence of abuse should be documented. Ideally, medications should be prescribed according to set protocols with defined quantities and intervals. Pain management and hospice services can be utilized when necessary. Pain medications are best used when integrated with other pain management modalities such as physical therapy, exercise, and healthy lifestyle habits. Attempting to have multiple physicians unbeknownst to each other prescribe pain medication is dangerous and illegal.

We want to insure that our patients to have adequate pain relief. For this reason, we do prescribe narcotic pain medications in the postoperative period. However, out of respect for the protection of our patients and their families we have developed standard pain management protocols. Our office policies restrict our staff from deviating from these protocols. The narcotic limits set to avoid abuse potential are liberal enough that nearly all of our patients find that they require less amounts of the pain medications than we have granted them access to. In fact, many patients find that they require no narcotics whatsoever. If you are on strong pain medication prior to surgery it is much more difficult to control your discomfort after surgery. If this is the case, we may refer you to pain management or have your primary care provider dispense all pain medications. 

Doing your part:

  • Maintain a positive attitude.

  • Relaxation and distraction techniques to calm anxiety. 

  • Participate in daily exercises if able to do so. 

  • Establish a routine to avoid frustration as normal activities may take more time. 

  • Move surrounding joints multiple times daily to avoid stiffness and discomfort.

  • Elevate the extremity to decrease swelling and discomfort.

  • If you have an external fixator, keep the pin sites clean to decrease irritation.

Medications to avoid if you have a fracture or have had surgery:

Attempt to avoid the following medications in the postoperative period as they may slow the healing process. It is ok for you to use Tylenol (acetaminophen) as directed if you have no other contraindications. Insure that your concurrent pain medications do not also contain acetaminophen as it can be dangerous to exceed the maximum daily dose.

 

Ketorolac

Toradol

Indomethacin

Indocin (SR)
Indochion (E-R)
Indomethacin (SR)

 Naproxen

Naprosyn
Aleve
Anaprox

 Ketoprofen

Orudis
ruvail

Tolmentin

Tolectin and
Tolectin DS

Ibuprofen

Motrin
Advil
Ibu-Tab
Children's Advil
Pediaprofen

 
 

Nabumetone

Relafen

Meclofenamate

Meclomen

Piroxicam

Feldene

Celecoxib

Celebrex

 
 

Much of the information above was derived from the following article:

Sohn D. Pain Meds Present Problems. AAOS Now. Jul 2013.