A Country Doctor Writes:

Specialists in orthopedics and general surgery often want us, the primary care doctors, to manage postoperative pain. I don’t like that.

First, I don’t know as much as the surgeons about the typical, expected recovery from their procedures. My own appendectomy in Sweden in 1972 was an open one that I stayed in the hospital for several days for (and nobody mentioned that there were such things as pain medications). I’m sure a laparoscopic one leaves you in less pain, but I don’t personally know by how much.

Postoperative pain could be an indicator of complications. Why would a surgeon not want to be the one to know that their patient is in more pain than they were expecting?

Pain that lingers beyond the postoperative or post-injury period is more up to us to manage. I accept my role in managing that, once I know that there is no complication.

I have many patients who hurt more that most people every time they have an injury, a minor procedure or a symptom like leg swelling, arthritis flare or toothache. The common view is that those people are drug seekers, taking every chance to ask for opiates.

I believe that is sometimes the case, but it isn’t that simple. I believe that people have different experiences with pain. We all know about fibromyalgia patients or those with opioid induced hyperalgesia, but pain is not a binary phenomenon. Like blood glucose, from hypoglycemia, through normoglycemia to prediabetes and all the degrees of diabetic control, pain experience falls on a scale from less than others to more than others.

I reject the notion that pain is a vital sign. When I was Medical Director in Bucksport I discouraged the use of numeric pain ratings. But I did encourage talking about the experience of pain as a subjective, nuanced and very valid consideration. We started a comprehensive pain education module for all our chronic pain patients.

I saw a patient just the other day with leg edema, who illustrates what I’m talking about:

Jim Gogan has had brief courses of hydrocodone over the years from different providers for everything from back strains to stress fractures to toothaches. Now he has very modest leg swelling that hurts him so much that he asks for pain medication.

He winced when I palpated his legs.

“This degree of swelling doesn’t usually hurt that much”, I said. “I don’t think I’ve ever seen someone needing hydrocodone for something like this.”

I went on to check the typical fibromyalgia tender points. About half of them were positive.

“Are you familiar with what’s called fibromyalgia? It’s a neurological condition where our pain sensitivity is tuned higher, like the volume of a radio. You are more sensitive to pressure and irritation in some of those spots, like you may have a touch of that phenomenon. There are treatments for that, but the scary thing about using hydrocodone or any other opiates for that is that we now know that they usually make it worse.”

I explained about opioid induced hyperalgesia. My short take is that the fast pain signals in our human nervous system give detailed information, like my left big toe hurts. If we suppress that signaling, an old remnant evolutional “lizard nervous system” gets ramped up. It is less precise, and may only tell us that there is tissue damage but it doesn’t know exactly what kind and where.

In my simple but, I believe, quite accurate explanation I then list the medications that work better when the pain signaling is in the ramped up slow nerve fibers at work in people on what I call the fibromyalgia spectrum.

If that isn’t a recognized term, like autism spectrum, perhaps we should all consider making it one.

Lo and behold, searching for “fibromyalgia spectrum disorder” there are many articles using that term, ranging from a 1993 editorial in Arthritis and Rheumatism, when the pathophysiology of fibromyalgia was still poorly understood, to a more recent 2008 review in The Journal of Clinical Psychiatry and current inferences in Pinterest and Facebook posts.

I have written before about how it can often be helpful to think of presentations that may not meet all the criteria of a given disease as still reasonable to approach as if they are milder forms on a spectrum. The longer I’m in this profession, the more sense that makes to me.

Shadow Syndromes