As a profession, orthopedic surgeons have developed good short-term
pain management programs. However, our role must be better
defined in the long-term prevention and management of
chronic pain. Chronic pain management should be more than
filling more opioid prescriptions and extending the patients
disability claim. We need to consider different approaches
when the musculoskeletal condition producing the original pain has not
One of the difficulties of chronic pain management is that there are no
diagnostic tests to consistently differentiate real chronic pain
from the symptoms rooted in secondary gains and emotional overlays. Scales,
psychological tests, pain drawings and selective blocks can be helpful.
However, orthopedic surgeons often find it challenging to differentiate
patients who can be helped from those who are malingers, drug dependent or are
working their disability situation.
Use and abuse of opioids
According to the Office of National Drug Control Policy, opioid
painkillers continue to be the most commonly prescribed medications in the
United States and are the nations second-leading cause of accidental
death after car crashes. A recent study published in the Archives of
Internal Medicine estimated that 15% to 20% of doctor visits in the
United Sates involve an opioid prescription. From 2000 to 2009, prescriptions
have increased almost 50% and the milligrams prescribed per person also
increased by 400% from 1997 to 2007, according to the study.
There is a tendency for busy physicians to keep prescribing opioids in
ever higher doses. It is difficult and time consuming to alter the
patients need and demands for ongoing pain medication. All of these drugs
are prescribed without any significant evidence that opioids are an effective
treatment for altering chronic pain symptoms.
Orthopedic surgeons treat a small percentage of the chronic pain
patients in the United States. Most of these patients are treated by non-MDs
(chiropractors, podiatrists, physical therapists, massage therapists, trainers,
nurse practitioners, physician assistants, etc.) and by other health care
specialties. The cost for all the combined treatments, medications and
associated lost wages in the United States is staggering.
We all see red flags during a busy office session. For example,
suspicions are increased if, after an evaluation and while you are making your
recommendations, the patient asks which specific pain medication are you
prescribing? You make a suggestion for what you believe is most
appropriate, and it is acceptable most of the time. Occasionally, the patient
will say something like, Nothing works for me except Percocet or
Oxycontin or My body finds the other pain medications are like
While you are processing this response, the patient may also request a
sleeping medication saying the pain prevents sound sleep. Such
patients stick to their requests and argue that nothing else works for them. At
some point during these conversations, patients may also ask you to
substantiate their disability claims and even ask if you will talk with their
Patients with chronic refractory pain usually have one or more of the
following characteristics in common: they have complaints of more than one
joint or specific area of pain; they have been out of work because of pain for
more than 6 months; they do not fill out a anatomic pain drawing; they often
have a lawyer representing them; and they are resistant to programs to reduce
their pain medications.
Variations in physician approaches
Most orthopedic surgeons have developed their own individual approaches
to the refractory chronic pain patient. However, there is a great deal of
variation in our approaches. Some orthopedic surgeons do not attempt to manage
chronic pain patients while others surgeons refill medications and follow their
patients for years. At some point in long-term pain management, the patient
should be evaluated in a multidisciplinary pain management program with ongoing
medical supervision and monitoring.
Over the years, I have read very little clinical research that has
assisted me as an orthopedic surgeon to successfully treat refractory chronic
pain patients. My preference was to tell chronic pain patients in a very
straight-forward manner if I believed I could not make a difference in their
chronic pain. When I could not help them, I would refer them for another
opinion. That is to say this was for the patients where I recognized the
chronic pain issues. I would occasionally learn that one of my patients was
also getting pain medications from more than one physician or forged my
I know some physicians look at every patient as a potential drug abuser.
This is in part because the clever patients are quite sophisticated to cover up
their addictions and resourceful to get prescriptions. We have our clinical
suspicions because we have learned from experience. Some physicians go as far
as having their patients take periodic urine tests or even sign treatment
contracts promising to take medications only as prescribed and not seek drugs
from other sources.
In California, we are fortunate to have help from prescription
registries that detect patients who get similar drugs from other physicians.
However, the registries suffer from compliance and funding issues and only
detect a small percentage of prescription drug addicts. In 2005, Congress
passed a national attempt at a similar prescription registry. President George
W. Bush signed the bill; however, its implementation has been hampered by
inadequate funding. Because chronic pain management is recognized as such a
large-scale problem, I had to take a test on chronic pain management at the
time of my relicensure in California. However, the reading materials for the
exam were not that helpful as they covered a fair amount of end of life pain
Pain management centers
In my experience, it has been disappointing that many of my patients
referred for chronic pain problems did not become more functional or ever
return to work. Many insurance carriers do not cover addiction treatment
programs. Or if they do, it is only for a short period of time and often
involve a re-evaluation process. However, there is hope as pain management
centers are evolving the process to include a multidisciplinary health care
team approach. Even with the pain management centers focused approach to
treating addictions, not every patient is successfully treated. Some patients
become dependent on methadone or simply continue to be disabled from pain.
Needless to say, preventing the scenarios which may lead patients to
becoming chronic pain management challenges is ideal. But it is a delicate
balance. On one hand, we have to practice tough love, but at the
same time, we cannot make patients feel as if we are telling them there is
nothing wrong from a medical standpoint and that their problems are mental. As
orthopedic surgeons, we would benefit from ongoing education and alternative
approaches to refractory pain related to the musculoskeletal system. Chronic
pain management needs to be more than simply filling opioid prescriptions and
extending disability claims.
- Becker WC, Tobin DG, Fiellin DA. Nonmedical use of opioid
analgesics obtained directly from physicians: prevalence and correlates.
Arch Intern Med. 2011;171(11):1034-1036.
- Douglas W. Jackson, MD, is Chief Medical Editor of
Orthopedics Today. He can be reached at Orthopedics
Today, 6900 Grove Road, Thorofare, NJ 08086; email: