--- title: 'A World Without Pain' type: 'lecture' url: 'https://doc.social/lectures/a-world-without-pain' published: '2021-12-19' author: 'Ira Kirschenbaum, MD' specialty: 'Orthopaedic Surgery' topics: 'Postoperative Pain' transcript: 'yes' --- # A World Without Pain Reasons why postoperative pain is not only painful to the patient but also to the healthcare system ## Summary This lecture describes a new way of looking at postoperative pain. It introduces the 7 Pain Points of Pain© which are the reasons why postoperative pain is not only painful to the patient but also to the healthcare system. ## Transcript 1,025 words · 8 min · 3 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source. [0:00] Speaker 1: Hello, I'm Doctor Ira Kirshenbaum. I'm gonna talk today about a way that we should be looking at Pain in a postoperative setting, essentially considering a world without Pain. [0:14] Speaker 1: There is no question that Pain is worldwide after any type of major joint Surgery, but the question really remains, what if we could do something about it in the key time periods that exist after Surgery. [0:35] Speaker 1: Here are my disclosures. I'm on the board of directors of SwiftPath, editor in chief of the Journal of Orthopedic Experience and Innovation, scientific advisory Board of Gate Science, and on the AAOS ICLS Practice Management Committee chair. [0:54] Speaker 1: We like to think that we're very advanced when it comes. [0:59] Speaker 1: To managing Pain in a postoperative period. [1:04] Speaker 1: This is evidenced by so many articles of people saying they do a certain amount of. [1:09] Speaker 1: Surgery with very few opioid pills or less, and in fact. [1:15] Speaker 1: It is common to use opioid consumption as the benchmark to whether you're managing Pain. [1:22] Speaker 1: But I actually think that we are way. [1:26] Speaker 1: Behind the eight ball is. [1:29] Speaker 1: We need to be considering where we need to get to concerning Pain as you can see from the slide this is where I think we are we need to rethink, reimagine, reinvent and disrupt the way we think about Pain. [1:48] Speaker 1: There's no question that there is a roaring opioid crisis in this country. [1:55] Speaker 1: But as surgeons, we need to think less about opioid sparing Surgery. [2:01] Speaker 1: But think of it as Pain sparing Surgery. [2:05] Speaker 1: Because if people take less opioids but do Other things to have Pain or just deal with the Pain, we have not dealt with the Primary problem which is Pain after Surgery. [2:18] Speaker 1: This is a previous video from a TV show called Name That Tune, I think you'll see the connection I'm making to a toward the attachment we have with opioid as a proxy for Pain. [2:38] Speaker 2: Washak can name that tune in 6 notes. [2:42] Speaker 3: Sandy. [2:44] Speaker 3: I can name that tune in 4 [2:46] Speaker 2: notes. [2:49] Speaker 2: Walsh, I can name that tune in 3 notes. [2:54] Speaker 3: Handy. [2:55] Speaker 3: Amen to. [2:57] Speaker 1: We could learn from this lesson. [3:00] Speaker 1: That the race is really not to how many opioid pills you can prescribe but rather how much Pain the patient has and what is their perception of that Pain. [3:15] Speaker 1: So it's very common in the postoperative period to think about the 1st 3 days, there are so many. [3:25] Speaker 1: So many. [3:28] Speaker 1: Modalities we use to take care of Pain in a perioperative period from the time of Surgery, perioarticular injections to various radio frequency cooling devices, long acting liposomal divvicane, long acting, uh, liposomal bupivacaine with, [3:55] Speaker 1: NSAIDs. [3:56] Speaker 1: And what really happens is the patient is aware that these are gonna last for about 3 days and they start with serenity which moves to anxiety, then some stress and then worry and then absolute fear when the 4th or 5th day is gonna come around so we need solutions after that 3rd day, but what is the issue really about Pain and why is Pain so painful for surgeons and patients? [4:29] Speaker 1: I created this concept of Pain points of Pain, what are the things about Pain that give us Pain, and I didn't put them in any specific order, but one of the things that we do, we'll start with the first one, patients deciding about Surgery. [4:48] Speaker 1: Many patients decide that they're not gonna have Surgery because the fear of Pain, so that is our first Pain point of Pain. Second is Pain increases length of stay or for a patient makes them decide not to have major joint Surgery in an ambulatory Surgery center. [5:07] Speaker 1: The third is that Pain causes emergency department visits and readmissions to the hospital. There are known studies that prove this. [5:18] Speaker 1: The fourth is that Pain interferes with Physical therapy, making it more difficult to go through the Physical therapy, and this would probably lead to adhesive capsulitis in the Shoulder or stiff Knee, leading again to lysis of adhesions or manipulation of the anesthesia. [5:38] Speaker 1: The 5th thing, increased calls to the office and office visits. This is time consuming and costly. The 6th, which is extraordinarily important, is decreased patient satisfaction with the Surgery and with the process. And the 7th, of course, extremely important is the risk of opioid addiction. [6:03] Speaker 1: So [6:04] Speaker 1: You can look at a concept which I developed called the Pain wheel. The 1st 30 days, if we really manage patients and ask them about their Pain for 30 days, we would see that maybe in the 1st 3 days it's very nice bright green, which is good in this situation, red being bad, and we see. [6:26] Speaker 1: That at various points of time in this 30 day period there'll be breakout points of Pain and various moments where Pain needs to be managed, so we definitely need solutions related to Pain in the 1st 30 days. [6:45] Speaker 1: We actually did a study in our hospital on emergency department visits following Total joint replacement in a closed urban setting, and this was a report of 1000 consecutive patients. We looked at 30 days and 90 days and just for this particular talk we looked at ED visits up to 30 days after Total Knee Replacement where 8%. [7:11] Speaker 1: Due to Pain and swelling, the charges average $1,142.69 and the collections average $311.83. Now the hospital I work in is primarily in a Medicaid HMO area, so. [7:26] Speaker 1: The payments are lower, but the payments would be much higher in certain community hospitals and certainly if the patient went to an emergency room that was not par with their insurance company, they would have to pay the entire charge. So if all the charges were paid, 1 million knees a year, which is a conservative estimate on how many knees are being done, would cost $1.14 billion a year just in emergency department visits. [7:56] Speaker 1: So I bring us back now in conclusion to the Pain points of Pain, and we can see that when we look at Pain, we have to think in terms of this entire wheel and its effect on all these things separately. [8:15] Speaker 1: Thank you for your time and listening to this talk.