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Safe and Effective Alleviation of Pain

Commentary on an article by Abhiram R. Bhashyam, MD, MPP, et al.: “Self-Reported Marijuana Use Is Associated with Increased Use of Prescription Opioids Following Traumatic Musculoskeletal Injury”

Ring, David, MD, PhD

doi: 10.2106/JBJS.18.00960
Commentary and Perspective
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Dell Medical School, The University of Texas at Austin, Austin, Texas

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Anyone who has observed people recovering from major injury or surgery in another country has likely witnessed comfort and appreciation with few or no opioids. Here in the U.S., we may likewise know friends and patients who get through big surgeries or injuries with few opioids. Studies show that, in the U.S., many people never fill their opioid prescriptions, and those who do often take just a few pills and then stop taking them1-3. How is this possible?

An opioid is a molecule that binds and activates the opioid receptors in our central nervous and gastrointestinal systems. Why do we have such receptors at the ready? Because our bodies make opioids. We make endorphins and enkephalins. The placebo effect is known to activate this “inner healer”: our innate physiology for recovery and resilience. The placebo effect can be blocked by opioid-receptor antagonists such as naloxone4.

Cultural differences that we may observe are probably due to more effective activation of this inherent health system. For instance, patients in the Netherlands take acetaminophen after ankle fracture fixation surgery and have comparable, or better, alleviation of pain than their U.S. counterparts, most of whom are prescribed oxycodone5. Inpatients recovering from orthopaedic surgery who take more opioids experience more pain6,7. Greater self-efficacy (“I just had surgery…my body needs time to heal…I’ll be fine”) and fewer symptoms of depression were associated with less pain and greater satisfaction with pain relief6,7.

Advocates and pharmaceutical companies created an opioid-centric strategy for the alleviation of pain, using subversive messages directed at physicians that amount to, “You undertreat pain, and you over-worry about addiction.” This, in turn, has reinforced a passive, pharmaceutical, or external power-focused approach to the alleviation of pain. If not opioids, then what medication? This approach ignores the evidence that addressing the psychological and social determinants of health seems to be the key to safe and effective alleviation of pain and optimal opioid stewardship.

The current study must be interpreted in light of the fact that it addresses self-reported cannabis use and opioids obtained within the health-care system. Another important point to note is that this study would not be possible under the recommended strategies for safe and effective pain relief promoted by the American Academy of Orthopaedic Surgeons (AAOS) and others (see the Pain Relief Toolkit on the AAOS web site: Patients in this study were prescribed opioids well after healing was established, which occurs within a few weeks of injury or surgery. There is evidence that the continued prescribing of opioids more than a month after injury or surgery represents misdiagnosis and mistreatment of symptoms of depression or posttraumatic stress, and less-effective coping strategies such as catastrophic thinking8,9. To limit misdiagnosis and to depersonalize discussions about another prescription (common enemy, “those darn rules” rather than “heartless, cruel doctor”), each orthopaedic practice can agree on a maximum strength, dosage, number of pills, number of prescriptions, and duration of opioid use for categories of injury and surgery. Beyond those maximums, help is obtained from primary care doctors, psychologists, psychiatrists, social workers, or addiction medicine specialists.

Some people tout cannabis as pain-relieving, and those who use it often swear by it. However, the data in this study suggest that individuals who use cannabis during recovery from fracture surgery use more opioids. There are several possibilities here: (1) the data from the psychological measures suggest that people who use cannabis may be self-treating psychological distress and have less-effective coping strategies, which is known to increase pain intensity for a given nociception; (2) cannabis users may represent a subset of people more open to external and pharmacological treatments and less interested in self-care and self-efficacy; (3) perhaps cannabis users are more open to substance use in general; (4) cannabis users may have a different conception of the “usual” use of opioids after fracture surgery, mistakenly believing that they use less.

All conceivable explanations for the findings of this study seem to support the weight of evidence that the alleviation of pain is largely an active process that can be learned, practiced, and improved on, rather than a purely passive process of finding the optimal chemical analgesic. Efforts to improve the safety and efficacy of the alleviation of pain can benefit not only from optimal pharmaceuticals but also from a focus on the psychological and social determinants of human illness.

Disclosure: The author indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest form, which is provided with the online version of the article, the author checked “yes” to indicate that he had a relevant financial relationship in the biomedical arena outside the submitted work (

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1. Feinberg AE, Chesney TR, Srikandarajah S, Acuna SA, McLeod RS; Best Practice in Surgery Group. Opioid use after discharge in postoperative patients: a systematic review. Ann Surg. 2018 Jun;267(6):1056-62.
2. Peters B, Izadpanah A, Islur A. Analgesic consumption following outpatient carpal tunnel release. J Hand Surg Am. 2018 Feb;43(2):189.e1-5. Epub 2017 Nov 7.
3. Rodgers J, Cunningham K, Fitzgerald K, Finnerty E. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012 Apr;37(4):645-50. Epub 2012 Mar 10.
4. Kaptchuk TJ, Miller FG. Placebo effects in medicine. N Engl J Med. 2015 Jul 2;373(1):8-9.
5. Helmerhorst GT, Lindenhovius AL, Vrahas M, Ring D, Kloen P. Satisfaction with pain relief after operative treatment of an ankle fracture. Injury. 2012 Nov;43(11):1958-61. Epub 2012 Aug 16.
6. Nota SP, Spit SA, Voskuyl T, Bot AG, Hageman MG, Ring D. Opioid use, satisfaction, and pain intensity after orthopedic surgery. Psychosomatics. 2015 Sep-Oct;56(5):479-85. Epub 2014 Sep 6.
7. Bot AG, Bekkers S, Arnstein PM, Smith RM, Ring D. Opioid use after fracture surgery correlates with pain intensity and satisfaction with pain relief. Clin Orthop Relat Res. 2014 Aug;472(8):2542-9. Epub 2014 Apr 29.
8. Helmerhorst GT, Vranceanu AM, Vrahas M, Smith M, Ring D. Risk factors for continued opioid use one to two months after surgery for musculoskeletal trauma. J Bone Joint Surg Am. 2014 Mar 19;96(6):495-9.
9. Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017 Jun 21;152(6):e170504. Epub 2017 Jun 21.

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