I often hear the mantra – “you must stay ahead of your pain, or else.” The president of the American Academy of Pain Medicine, states a common mistake people make, is waiting too long to take pain medication. By the time you’re in pain, you’re starting from behind the eight ball. "It takes a lot more medicine to control pain after it’s started as opposed to starting it ahead of time," he says.[i]Is this true, if I don’t pre-empt my pain I will be doomed to a never ending cycle of playing catch up? There are a lot of smart people and prestigious organizations espousing this theory of staying ahead of your pain so maybe we should move on and accept it as settled science, right?
Well as it turns out, there is a lot more to treating acute pain than sending patients home with a prescription of an opioid mixed with acetaminophen and telling them to just take what you feel you need so that your pain never gets “severe.” Do patients have any idea what this means? Of course no!
Since non-opioid analgesics should be used as the foundation of acute pain management, sending patients home after surgery, for example, with a combination opioid defeats the purpose.
Rule # 1: Assuming you have no renal or liver disease, you should take close to the daily maximum of acetaminophen and a non-steroidal anti-inflammatory agent around the clock.
Rule # 2: Opioids should only be used in their pure form; they should be taken only when the patient feels their pain is intolerable and then stopped as soon as possible.
Rule # 3: The 24hr opioid prescription dose should be calculated so that the morphine milligram equivalents (MMEs) are less 50 for all opioid naïve patients.
Let’s unpack how these rules fly in the face of current medical management. Most patients are prescribed a combination opioid for acute pain. This means that you will always max out on the opioid component prior to the non-opioid – not good. Most clinician do not calculate the MMEs they prescribe and have no idea at what level an opioid naïve patient is at increased risk for respiratory depression – not good. Patients are not told to take a pure opioid if their pain becomes intolerable while on scheduled non-opioid multimodal treatment – not good.
When patients are coached to stay ahead of their pain they invariably overtreat with opioids due to fear of what “may” occur. By overtreating, you end up suppressing your ability to make endogenous opioids thus causing an amplification of pain once the prescription ends. Post-surgical pain is expected and when treated in keeping with the above rules most patients will be managed with tolerable pain. This tolerable pain allows you to progress with the healing and rehabilitation process, but more importantly, allows your brain to manufacture endogenous opioids – very important. Central sensitization of pain, opioid induced hyperalgesia, the progression to chronic pain, and persistent use of opioids after 90 days, are all the results of overtreatment.
So, the next time you hear the phrase, “stay ahead of your pain,” remember to “stay ahead of the pack” and utilize a non-opioid multimodal foundation first, followed by a pure opioid only when the pain becomes intolerable. This may fly in the face of current medical management, however, last time I checked, this philosophy was a main driver for our current opioid epidemic.
Myles Gart, MD
Dr. Gart is an anesthesiologist
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