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Safe and Effective Alleviation of Pain
David Ring MD PhD
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Disease vs. Illness
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Nociception vs. Pain
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Sociology: Netherlands vs. USAProspective cohort study• ORIF ankle fracture• NL: acetaminophen or tramadol• USA: oxycodone• Equal pain intensity• Equal satisfaction with pain relief
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Psychology: Inpatients after Orthopedic Surgery
Greater pain intensity / lower satisfaction: • More opioids (oral morphine equivalents)
Lower pain intensity / higher satisfaction: • Fewer symptoms of depression• Greater self-efficacy
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Pain Relief After Fracture Surgery• More opioids = more pain• Not related to nociception• Comfort associated with self-efficacy
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Opioid Intake 1-2 Months After Surgery• PTSD• Symptoms of anxiety• Symptoms of depression• Catastrophic thinking
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After Fracture• Depression
– 1-2 months: 26%– 6-8 months: 21%
• PTSD– 1-2 months: 32%– 6-8 months: 18%
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OpioidA molecule that binds to and activates opioid receptors
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Legislation• Opium Exclusion Act 1909• Harrison Narcotics Tax Act 1914• Heroin Act 1924• Food, Drug, and Cosmetic Act 1938• Controlled Substances Act 1970• DEA formed 1973
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“Pain is the 5th Vital Sign”• International Association for the study of
pain (IASP)• Initial wide adoption in VA hospitals
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JACHO (now the Joint Commission)• 2000 release standards on pain management
– Do not mention opioids• Released pain CME booklet sponsored by Purdue that
said: “Some clinicians have inaccurate and exaggerated concerns” about addiction, tolerance and risk of death, the guide said. “This attitude prevails despite the fact there is no evidence that addiction is a significant issue when persons are given opioids for pain control.”
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Iatrogenic & Advocatogenic
• You undertreat pain• You over-worry addiction
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Alleviation of Pain• Effective communication strategies• Effective planning and preparation• Screening• Depersonalize it: stick to the strategy
– Reasonable maximum amount of opioids• Mindset:
– Compassion, trust– Stress, distress, effective coping strategies