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Am Fam Physician. 2018;97(3):203-204

It was chilly but still a nice day for a dog walk. Having forgotten gloves, I had my hands in my coat pockets, and the leash was wrapped around my wrist. Headphones on, I wasn't paying attention to the ground. I tripped on some loose rocks and fell. The pain in my arm was immediate and intense. X-rays revealed that I had broken my shoulder, but the ER doctor assured me that it would heal on its own if I kept my arm in a sling. I was sent home with a prescription for Percocet.

Fifteen days after the fall, it turned out that I needed open reduction surgery on my proximal humerus after all. I left the hospital with a peripheral nerve block and prescriptions for more opioid pain medications. I followed this regimen for three weeks. My surgeon told me that it is better to take the medications before the pain resumes, so I set up a timed pill schedule and recorded each dose. These medications greatly reduced the pain, but I was nauseated, had no appetite, and felt drugged and disconnected. When my prescriptions ran out, I stopped taking the pain medications. I had been on opioids for the five weeks since my fall, and I wanted to feel normal again. However, I was not prepared for how horrible I would feel withdrawing from these drugs. I became emotionally unstable, suspicious, depressed, teary, and hopeless. I could not sleep without sleep aids, and I battled diarrhea and a queasy stomach for 10 days. Directly after the accident and postsurgery, I was desperate for pain relief, and the narcotics worked like magic. The adverse effects were not trivial, however, and withdrawal is something I never want to experience again. I wonder if there was another way the doctors could have managed my pain.—L.H.

Commentary

In 2015, prescription opioids were directly responsible for more than 22,000 deaths.1 Nearly 2 million individuals nationwide have prescription opioid use disorder.2 Many patients are first exposed to opioids following surgery.

How could LH's difficulties with stopping opioids been avoided? Although the Centers for Disease Control and Prevention has published guidelines for treating chronic pain with opioids,3 there are no consensus guidelines for prescribing opioids for acute peri- and postoperative pain, leading to wide variations in practice.4 Acute pain can be addressed using the World Health Organization's pain relief ladder, in which nonopioid medications (e.g., nonsteroidal anti-inflammatory drugs, acetaminophen) are used before considering opioids, and opioids are used on an as-needed basis before considering scheduled use.5 A recent study found that for moderate or severe extremity pain, a combination of acetaminophen and ibuprofen had similar reductions in two-hour pain scores compared with opioid analgesics.6 Opioids should be used judiciously given the risk of chronic dependence that might begin with the unpleasant adverse effects associated with withdrawal. A recent study found that in a cohort of more than 36,000 patients who underwent minor or major surgery, 5.9% to 6.5% had persistent opioid use 90 days after surgery.7 Persistent postsurgery opioid use is independently associated with preoperative tobacco use, alcohol and substance use disorders, mood disorders, anxiety, and pain disorders.7

Physicians should counsel patients about the potential harms of opioids during preoperative medical evaluations and assist with developing a perioperative pain management plan. After surgical procedures, guidelines from the American Pain Society can be followed, including judicious use of opioids, longitudinal use of a validated pain assessment tool with dynamic adjustment of medication regimens based on the World Health Organization pain relief ladder, and possible use of transcutaneous electrical nerve stimulation and cognitive behavior modalities such as guided imagery and hypnosis.8

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