Pain Management in Musculoskeletal Disease
Opioids are commonly used for the treatment of acute pain. The United States has experienced an increase in the rates and quantities of opioids prescribed with a peak in 2010. Although the rate of prescriptions has declined, the amount of opioids prescribed in 2015 in the US is still four times higher than in Europe and three times higher than in the United States in 1999. Unfortunately, the rise in prescribing has paralleled a sharp rise in opioid-related overdoses and the rate of opioid-related deaths has continued to increase.
Orthopedic surgery is often times associated with substantial perioperative pain The fear of this pain has been cited as a major reason why patients delay knee or hip arthroplasty.
At this time opioid use for chronic and acute pain is common. Orthopedic surgeons are frequently the individuals writing the prescriptions for these drugs. Prescriptions for opioids occur with high variation for acute pain. Incorporation of a multimodal pain management strategy is an important part of any well-designed pain management program.
Although opioids are effective in the management of acute musculoskeletal pain the morbidity and mortality related to their use reinforces the need for robust evidence-based guidelines. Orthopedic surgeons and other providers of musculoskeletal care should evaluate patient risk preoperatively and prescribe judiciously.
The international Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” Differentiating acute pain from chronic pain is based on timing and the duration of acute pain reflected in the mechanism and severity of the underlying cause. Acute postoperative pain is expected to subside during the process of tissue healing typically within three months after a procedure.
Degenerative joint-related pain in osteoarthritis is highly prevalent and occurs in about 12% of the population of United States. Primary total hip and knee arthroplasties are among the most common surgical procedures performed in the US. The prevalence of these procedures is expected to continue as a result of the aging population. Low back pain is the second most common symptom presenting for a physician visit in the United States and opioids are commonly prescribed for chronic pain relief. Preoperative use of opioids is common and reported in 65% of patients presenting for spinal procedures and 33% of patients presenting for joint arthroplasty.
Although opioids are is effective for the management of musculoskeletal pain, morbidity and mortality associated with their use reinforces the need for evidence-based guidelines. Despite research on the effectiveness of opioid alternatives such as NSAIDs, acetaminophen, and gabapentinoids, there is not a large body of evidence on the comparative effectiveness of these strategies. There is even less research addressing the comparative efficacy of pharmacological and non-pharmacological methods of the pain management. Further research must address these gaps in our knowledge.
- LDelaney et al. J. Bone Joint Surg., 2020:102 Suppl 1:3-9.