Pain options for primary care while awaiting orthopaedic surgery
We are all aware of the pressures on elective surgery due to the pandemic. With this (and other factors) we have seen a national spike in opioid use.
Patients with osteoarthritis awaiting surgery have what the recent NICE guidelines refer to as “secondary chronic pain” (i.e. a pain of 3 months or more with a known identifiable cause). This can be a really difficult time for patients especially as they may believe that surgery, and medication for pain in the meantime, is the only way to relieve their symptoms. However, this is not necessarily true. The long term use of medication for pain, even while awaiting surgery, is not recommended by NICE. We know that opioids beyond 12 weeks carry more risks than benefits and there is also little evidence to support the use of gabapentinoids. Long term opioid use in advance of surgery is linked to a higher risk of long term opioid use following surgery. So it’s best not to add these medications to repeat and to always consider providing the MHRA leaflet on opioids , if prescribing at all.
Some available options for you to provide to patients to who are struggling with chronic joint pain and may or may not be on a list waiting for joint surgery could include:
- Escapepain for osteoarthritis pain . In Somerset this is accessed via physiotherapy. Consider discussing this with your first contact practitioner so that patients can be appropriately referred.
- Chronic pain (including osteoarthritis) has an impact on emotional health, especially if hoped for treatments are delayed or do not provide the desired outcomes. All patients with any long term conditions (including chronic non cancer pain) should be directed towards an emotional health check at Emotional Health Checks - Talking Therapies – Somerset IAPT Service (somersetft.nhs.uk).
- Short rescue prescriptions only for the acute pain (e.g. no more than 4 days – longer than this can be linked to chronic use) with clear advice around use and how long the prescription is for. Longer term opioid use leads to “opioid induced hyperalgesia” which mimics the underlying pain problem and perpetuates it. Pre-operative regular opioid use of more than 3 months is a high predictor for long term use post surgery.
- This patient information leaflet on other pain strategies can be adapted for your practice
- SCPMS are also always happy to provide further advice. Formal advice and guidance is due to become available during October but they are happy to be contacted directly in the meantime.