Self-Reported Pain Tolerance and Opioid Pain Medication Use after Foot and Ankle Surgery

Abstract

Category: Pain Management Introduction/Purpose: The opioid epidemic in the United States continues to take lives. As one of the top prescribing groups, orthopaedic surgeons must tailor post-surgical pain control to minimize the potential for harm from prescription opioid use. Patients often reference their own pain threshold as a benchmark for how they will tolerate the pain of surgery, but current literature suggests that there is not a significant correlation between an individual’s perceived pain threshold and their actual threshold for heat stimulus. The purpose of this study was to determine whether there is a correlation between a patient’s self- reported pain tolerance and their actual prescription narcotic medication usage after foot and ankle surgery. Methods: This was a prospective cohort study of adult patients that underwent outpatient foot and ankle surgeries performed by 5 fellowship-trained foot and ankle surgeons at a large, multispecialty orthopaedic practice over a one year period. Demographic data, procedural details and anesthesia type were collected. Narcotic usage data including number of pills dispensed and pill counts performed at the first postoperative visit were obtained. Patients were contacted via email or telephone between 7-19 months postoperatively, and asked to respond to the validated statement “Pain doesn’t bother me as much as it does most people” by choosing “strongly disagree”, “disagree”, “neither”, “agree” or “strongly agree”. Patients scored their pain threshold on a scale of 1- 100 with 0 being “pain intolerant” and 100 a ”high pain threshold" and ranked their expectations of the pain after surgery and satisfaction with pain management on respective five-point Likert scales. Data was analyzed using a Spearman’s correlation. Results: Of the 486 patients who completed surveys, average age was 51.24 years, 32.1% were male and 7.82% current smokers. After controlling for age and anesthesia type, both agreement with the validated statement and higher pain tolerance score had a weak negative correlation with pills taken (r=-0.13, p=0.004 and r=-0.14, p=0.002, respectively); patients with higher perceived pain thresholds took fewer opioid pills after surgery (Table 1). Correlation between high expectations of postoperative pain and pills taken was weakly negative (r=-0.28, p=<0.001) (Table 1). Patients who found surgery more painful than they expected took less pain medication. There was a small, positive correlation between pain tolerance and satisfaction with pain management (r=0.12, p=0.008), indicating that patients with a relatively high pain tolerance had more satisfaction (Table 1). Conclusion: Assessment of both subjective description and quantitative score of a patient’s pain threshold prior to surgery may assist the surgeon in tailoring postoperative pain control regimens. Unexpectedly, patients who found surgery less painful than expected actually took a greater number of opioid pills. This may highlight an educational opportunity regarding postoperative pain management in order to reduce narcotic requirement. Setting expectations on safe utilization of prescribed pain medications may also increase satisfaction. This study provides useful information for surgeons to customize pain management regimens and to perform effective preoperative education and counseling regarding postoperative pain management. Table 1. Correlation Between Pain Threshold Assessment, Expectation of Postoperative Pain and Satisfaction with Postoperative Pain Management and Opioid Medication Taken Spearman Correlation Coefficient p-value Agreement with statement “pain doesn’t bother me as much as it does most people” and opioid intake -0.13 0.004 Increasing quantitative pain threshold score and opioid intake -0.14 0.002 Assessment of postoperative pain as more painful than expected and opioid intake -0.28 <0.001 Increasing satisfaction with postoperative pain management and opioid intake 0.12 0.008