LONGER TERM PAIN

PERSISTENT POST-SURGICAL PAIN, CHRONIC PAIN & NERVE PAIN

Pain is obviously unpleasant but it can provide some form of protection in the form of feedback to allow us to recognise & avoid potentially dangerous situations. A simple example might be pain from a broken leg. The pain is a signal not to walk on the leg. However some pain signals serve little purpose and can exist when there is no obvious threat. Pain can persist after an operation long after the wound has healed. This is termed persistent post-surgical pain or 'chronic pain'. It is a complex process where by the body perceives ongoing injury and produces and amplifies pain signals where no obvious injury is evident. However the pain is very real. There may be features of burning sensations or electric shocks, painful sensations from non-painful stimulus, such as a light touch, temperature and skin changes. These are all signs of a specific type of chronic pain termed "nerve pain".

Treatment of established chronic pain or nerve pain is challenging and may require consultation with pain specialists and many other teams including nurses, physiotherapists and psychologists in partnership with GPs. 

Prevention of this condition includes avoidance of severe pain after surgery where possible, early recognition of the condition and specialist attention with a variety of techniques and medications. Careful management of Narcotic or Opioid (morphine based) medications is also essential. While these medications may be required in the early phase after major surgery to manage severe pain, over time they become less potent and tolerance builds up. Furthermore, sensitivity to pain may actually increase with continued use of opioids and some opioids may be more problematic than others. This increased sensitivity to pain combined with reduced responsiveness to opioids can lead to a vicious circle of worsening pain. The immune system can also be affected and the risk of joint and prosthetic infections can be higher.

The aim to reduce and stop opioid medications as soon as practical after surgery. The time frame is different everyone but for example if you have NOT been on these medications BEFORE a joint replacement then ideally we would hope that you would be able to stop using these within 4 weeks after a knee replacement or sooner after a hip replacement. If you still require opioids at 6 weeks it is important that you consult with your GP to provide clear support and guidance on how to proceed. This may include reviewing or excluding any potential surgical factors contributing to the pain, adding in non-narcotic pain medications, changing the medication to other types of pain relievers and developing a structured withdrawal program for narcotic reduction. It may become more difficult to stop taking opioids if using them for longer than 3 months. Some studies suggest that ~8% of patients who were never on opioids before surgery may still be taking them 6-12 months after surgery. While we rely on GPs to provide this type of care for most patients if you are having difficulty managing your pain you may also benefit from a review by a pain specialist. A referral can be made directly from your GP or via The Joint Studio.

If you have been taking opioid medications BEFORE your operation for pain management your risks of remaining on opioids several months or longer after your surgery are higher. Up to 50% of patients may remain on opioids 1 year after surgery regardless of the improvement in the particular joint pain. These risks are higher if a patient has been on opioids for a longer period before surgery (> 3 months) or at higher doses. This may occur regardless of how successful the operation is. This risk can be reduced however with careful management. BEFORE your operation you may be advised to reduce the amount of pain medication you are taking. This may require weekly reductions of 20-50% in dosage until the agreed 'target' dose is reached and then kept at a steady level for at least 4 weeks. This may significantly help smooth your recovery and make pain management easier AFTER your surgery and improve your chances of stopping NARCOTICS altogether in the longer term.

© MJLennon FANZCA

Affiliated with The Joint Studio

 Hollywood Medical Centre

Suite 1, 85 Monash Avenue

Nedlands

Western Australia 6009