VITAL CARE COORDINATION IS LACKING WHEN ACUTE PAIN ARISES IN INDIVIDUALS LIVING WITH CHRONIC PAIN
By Rebecca McKinsey
Sharon Field, 63, has managed her debilitating back pain and osteoarthritis for almost two decades with prescribed opioids. But when she had a knee replacement surgery scheduled for the summer of 2022, she knew her pain would increase for a while.
Normal protocol would be to prescribe short-term opioids to help manage the acute pain following the surgery—but since Field, who lives in Florida, already takes opioids for her chronic pain, her surgeon didn’t prescribe additional painkillers following her surgery, despite Field’s efforts to coordinate a treatment plan with her pain management doctor before the procedure.
“I wasn’t heard at all,” Field says. “They don’t see the difference between acute pain and chronic pain.”
To manage the breakthrough pain from the surgery, Field took additional doses of her regular opioid—which meant she ran out of the medication before she was due for a refill. Those days without medication were excruciating. In addition to the untreated pain, her body experienced withdrawal symptoms.
“It was panic, it was pain, it was feeling probably the lowest I’ve felt,” she recalls. “I felt totally isolated. I felt shameful for needing this.”
For several weeks, her unmedicated days of pain kept Field from being able to participate in the physical therapy that was an important part of her surgery recovery.
Months later, she still chokes up thinking about the darkness of those days.
“You just lay in bed in a ball and hope the next day comes where you feel better,” she says. “That’s it.”
When chronic pain is present, acute pain acts differently
Managing acute pain in people already living with chronic pain is tricky, because those individuals’ nervous system treats pain differently, says Anjana Kundu, MD, anesthesiologist-in-chief at University of Rochester’s Golisano Children’s Hospital and a board-certified pediatric anesthesiologist, pediatric pain, and palliative care physician.
Acute pain is a protective mechanism against something the body sees as a threat, Kundu explains, likening it to the response that causes you to move your hand away from a hot stove.
“There’s a protective aspect of acute pain that is no longer true for chronic pain,” she notes. “In chronic pain, the pathways along which pain signals travel to your brain have altered over time for a multitude of reasons. There is no longer the reflexive move of the hand from the danger zone; there’s just pain, pain, pain.”
Acute pain can be more intense for individuals with chronic pain, Kundu says, requiring a specialized treatment approach that takes the patient’s pre-surgery baseline into account.
“If someone is already taking opioids, that’s their baseline need, their starting point,” she says. A coordinated plan should determine what additional treatment is needed on top of the basic need.
Sean Mackey, MD, PhD, chief of the Division of Stanford Pain Medicine in Palo Alto, California, often runs into this situation.
“If the patient is on pre-existing opioids for a chronic pain problem, they should be maintained on their baseline level of opioids up to surgery—this is not the time to make significant changes,” Mackey says. “Depending on the nature of the surgery, the patient may need some additional opioids for a short period of time after surgery.”
However, when possible, Mackey recommends optimizing other approaches, including non-opioid painkillers such as NSAIDs, acetaminophen, or gabapentinoids; regional anesthesia; mind-body techniques; external devices such as TENS units; heat or cold therapy; and more.
“It is good to have a clear, written plan on how to put all these tools together during the perioperative period and who will be responsible for what,” Mackey says. “It’s critical to have good coordination of care across all the clinicians, staff, the patient, and their family.”
Kundu suggests finding someone to advocate for you if needed, and being specific in your request, rather than simply saying a temporary increase in dosage is needed.
For instance: “I feel this is the bare minimum I need, now that I’ve had surgery, for me to be able to progress and get better. It’s important for me to participate in physical therapy. I need a little more help, because this [current prescription] is already my baseline before I came into surgery.”
“Just like you would optimize diabetes or asthma before a surgery, one needs to be sure to establish a baseline for chronic pain,” Kundu says.
Expectations low for second painful surgery
Field needs a second knee replacement once she finishes paying off her first, and she fears her excruciating recovery will be repeated.
“I’m not asking for the world here,” she says. “I will have the discussion, because I’m pretty proactive and I do speak up for myself, but I don’t have any hope it’ll change.”
Field says she feels as though she needs to tread carefully in conversations surrounding her opioid prescription, particularly following the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain that has made many doctors hesitant to treat chronic pain with opioids. She notes that she has been on the same, relatively low dose of opioid medication for all of the years she has taken it, even though at times she has felt that an increase in the dose would better help manage her chronic pain.
“You have to be really careful,” she says. “Don’t rock the boat.”
Field would like to see more coordination between providers to help individuals living with chronic pain deal with the breakthrough pain caused by medical procedures.
“Some empathy around it would be great to start with,” she says. “You’d think there would be more discussion around this process, policies with how to deal with it, and there’s nothing. This is obviously an issue. Just take it seriously.”