Primum non nocere.  First, do no harm.

All doctors are familiar with this credo. From ancient precepts such as the Hippocratic Oath promising to abstain from doing harm to the modern bioethics principle of nonmaleficence, the calling of physicians involves striving to help alleviate suffering and avoid making it worse. In our increasingly complex health care and data environment, avoiding inadvertent harm can be more difficult than one might expect.

I attended medical school in the late 2000s and completed my residency training in orthopedic surgery during the first half of the 2010s. It was a ten-year period during which pain was emphasized as a “fifth vital sign,” placing it in the hierarchy of crucial indicators of being alive along with heart rate, blood pressure, temperature, and respiratory rate. Pain had historically been undertreated in a system that was not patient-centered, and patient advocates rightly lobbied for increased attention to this aspect of the patient experience.

Unfortunately, the medical community’s response to this deficiency was pharmaceutically-based and lacking in nuance. Spurred on by the insidious actions of the manufacturers of opioid medications, these drugs assumed a far too prominent role in the treatment of pain. We were told repeatedly in medical school that one could not become addicted to a drug so long as it was administered to treat pain and that addiction was only a risk when opioids were consumed in the absence of pain. This turns out to be patently untrue.

As residents training at a major academic medical center with its own stand-alone orthopedic specialty hospital, we helped care for a steady flow of patients undergoing all manner of orthopedic surgery, with a large volume of elective total hip and total knee arthroplasty. Anyone who has undergone total knee arthroplasty or cared for someone who has will know that this can be an extremely painful experience.

House staff was the first providers to be called to address inadequate pain control. Every patient had as-needed opioid analgesics ordered. Early on, these were even intravenous opioids, often in the form of a patient-controlled analgesia (PCA) pump, where a shot of opioid could be directed into the patient’s vein at the push of a button. How patient-centered! Anyone not comfortable on the standard doses got a pain management consult, often leaving the hospital with hefty opioid prescriptions written by the pain docs.

Later in the 2010s, the medical community became increasingly aware that we were doing our patients a disservice. The use of opioid medication was not only a blunt instrument where a fine was required, but opioids were wreaking havoc on communities on an epidemic scale with the rise of synthetic opioids.

Orthopedic surgeons rank third among medical specialties in the prescribing of opioid medications. As prescribers, we have a lever to pull to affect the amount of opioids in our communities. Patients often save unused prescription pain medications “just in case.” Unfortunately, these may then be used by other members of the household or diverted to the street.

Opioids should not be a centerpiece of our arsenal of analgesic techniques. We can do better for our patients and communities while maintaining a focus on the patient experience and adequacy of pain control. My experience with opioid-free anterior cruciate ligament (ACL) reconstruction confirmed this. For over a year now, I have not prescribed opioid analgesics to any patient under age 25 undergoing ACL reconstruction. I advise all patients and their families that I will prescribe an opioid if necessary, but not a single one has taken me up on the offer. We routinely collect visual analog scale (VAS) pain scores two weeks postoperatively. Far from increasing, these have slightly decreased.

How do we manage this? All patients meet with the physical therapist before surgery and within two days after surgery. They use transcutaneous electrical nerve stimulation (TENS) before and after surgery. They get a regional anesthetic block from one of our anesthesiologists, supplemented with local injection during surgery. They use a cold machine to provide continuous cryotherapy. Standard medication prescriptions include a non-steroidal anti-inflammatory drug (NSAID), acetaminophen, and gabapentin. Also recommended is a cannabinoid. This is cannabidiol (CBD) for our patients, without tetrahydrocannabinol (THC), the active ingredient in marijuana.

With this multimodal approach, we have effectively eliminated opioids from ACL surgery for young people without compromising pain control. The most important intervention, however, costs nothing and has no side effects. This is a change in mindset. The mindset of the physician and the mindset of the patient. As physicians, we need to let go of the idea that opioids need to be on hand “just in case.” Patients want to know that their pain will be controlled after surgery. Simply discussing this and promising to make reasonable efforts to control (not eliminate) pain empowers the patient to undergo surgery without the fear and anxiety of uncontrolled pain.   Without belittling or undermining the fact that patients’ pain can be very real and excruciating, we must understand and communicate that the experience of pain is affected by many social, emotional, and neurophysiological elements. We can help our patients choose a pain experience in which they have agency that is not ceded to the pain itself or to the physician and, in so doing, do less harm to our patients and communities.

Michael Day is an orthopedic surgeon.

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