Same Injury, Different Pain Plan: Why We Treat You as We Find You

Two people with the same injury often need two different pain plans. Pain, and the risk that comes with pain medicine, depends on the person as much as on the X-ray: their history, their sleep, their mood, their work and how their nervous system reacts to trauma. Good care starts with the patient in the room, not with a template.

I got a hard lesson in this on October 11, from the other side of the stretcher.

What happened to Dr. Padda on October 11?

Around 5:50 that Sunday morning, on the way to the gym, I spotted a car in flames on the highway and pulled over. A woman needed help getting out. As I got her to the shoulder, another vehicle hit me and drove away. She did well.

My list: in the left leg, breaks in the medial malleolus, the bony bump on the inner side of the ankle, and in the fibula; a laceration close to 15 centimeters long at the ankle that tore the tibial artery; loss of roughly 40% of my blood volume, with the trauma team activated; and two broken ribs. No surgery was required, and the wound was closed. Work has gone on without a missed day. Long periods on my feet are still out, so my procedure days have been lighter than normal. Update, October 26: full function arrived on time, and my procedure days are back to their usual length.

The ER offered me opioids repeatedly. I said no each time. That choice fit me. Whether it fits you is a different question, and that is the subject of this article.

Why can one fracture call for two different plans?

Because the fracture is only half the problem. The other half is the person it happened to.

Picture two patients with the same broken ankle on the same night. The first is 34, works construction, sleeps well, has never filled an opioid prescription and does not smoke. The second is 61, smokes, has had low back pain for a decade, takes medication for depression and was on an opioid for months after a shoulder operation. On the imaging they are identical. In every way that predicts how their pain will behave, they are not.

The research backs that up from three directions.

• The body’s own painkillers differ. After trauma, the brain can switch on stress-induced analgesia, a descending pathway that blocks pain using endorphins, adrenaline-related signals and several other chemical systems. How sensitive people are to it varies greatly between individuals.¹ In 1946, Henry Beecher studied men with serious battlefield wounds. Many described far less pain than their injuries suggested, and a lot of them never asked for relief.²
• The risk of staying on opioids differs. Among adults who had not been taking opioids, between 5.9% and 6.5% kept filling prescriptions months after minor or major surgery, against 0.4% of people who had no operation. The size of the surgery did not predict it. Smoking, substance use, mood or anxiety disorders and earlier pain did.³ Our second patient carries almost all of those. The first carries none.
• The first exposure differs. In opioid-naive adults, the likelihood of long-term use rose with each additional day in that opening course. It climbed most steeply once therapy passed its fifth and thirty-first days, when a refill or second prescription followed, when the cumulative total hit 700 morphine milligram equivalents, and when the opening prescription covered 10 or 30 days.⁴ The same 30-day prescription lands very differently on those two people.

A single protocol, written for an average patient who does not exist, treats both of them wrong. One gets more medicine than they need. The other may get a plan that ignores the history most likely to hurt them.

What made declining the right plan for me?

Two things, both specific to me.

The first was the on-ramp. Chronic opioid use usually begins with one initial exposure, so keeping that exposure small is worth real effort. Why give my nervous system a head start toward a drug I might never need?

The second was my own chemistry. My own endorphins and epinephrine were elevated enough that the pain barely registered. A different person with the same injuries could have been in agony with that ankle, and they would have needed a different answer.

What did my pain plan actually include?

For the first couple of days: ibuprofen and acetaminophen, plus four devices: TENS; EMS, which stands for electrical muscle stimulation; a vibration plate aimed at one area; and infrared light. The devices are distractive tools. They give the nervous system something to process besides pain. That is the honest description, and it is not a woo-woo pitch.

• Ibuprofen and acetaminophen. In a randomized trial of 411 emergency department patients with acute arm or leg pain, one dose of 400 milligrams of ibuprofen with 1,000 milligrams of acetaminophen relieved pain at the two-hour mark just as well, statistically and clinically, as three opioid and acetaminophen combinations.⁵ That was a single dose, and adverse events were not measured. It is still a plan to check with your own doctor, especially with kidney disease, ulcers or blood thinners.
• TENS and EMS. Large nerve fibers that carry touch compete at the spinal cord with small fibers that carry pain. That is the gate control theory.⁶ A meta-analysis of 381 randomized trials covering 24,532 people found lower pain during or right after TENS than with placebo, moderate-certainty evidence, no serious adverse events, and no difference between acute and chronic pain.⁷ Read about TENS therapy after an injury and the home TENS unit.
• Vibration. Vibration stimulates the same large fibers. See vibration therapy after a car accident.
• Infrared light. The mitochondrial enzyme cytochrome c oxidase absorbs these wavelengths, which raises ATP and calms inflammatory signals in stimulated cells. Most of that research was done in cells and animals, some of it in models of traumatic injury.⁸ Our version is laser therapy for pain after an injury.

All four tools are part of our physiotherapy program after an accident.

Does treating you as we find you ever mean an opioid?

Yes. My approach was personal, and it may not be the right road for you. Plenty of patients genuinely need an opioid, and withholding them from someone in severe pain is its own kind of harm. Saying no is a real choice. It does not always work, but sometimes it does, and the system rarely puts it on the table. Both of those statements are true at once.

What we refuse to do is decide before we have met you. Every person is different. We take patients as they actually arrive, not as a chart or a stereotype predicted they would.

Where does opioid stewardship fit in individualized care?

Stewardship is harm reduction for one person. It is not a blanket ban, and it is not a blanket yes. For the first patient above, it might mean no opioid at all. For the second, it might mean a short, carefully watched course with a stop date, or a plan built around injections and physical tools instead.

For patients who already take opioids and want to come down, we taper with interventional procedures that treat the source of the pain, and we keep them out of withdrawal while we do it. You can read how that works in what happens to your prescription when the pain gets treated, on our opioid stewardship page, and under medication management.

What will we ask you at the first visit?

Expect questions that have nothing to do with the X-ray, because they shape the plan more than the X-ray does:

• Have you taken opioids before, and how did stopping go?
• Do you smoke, drink or use other substances?
• How have you been sleeping, and how is your mood?
• Did you have pain somewhere else before this injury?
• What does your work or home life need your body to do this week?

Your answers are not a test. They are how we build a plan for you instead of for a statistic.

Written by Dr. Gurpreet Singh Padda, MD, MBA, MHP, from his own recovery.

Sources

• Butler RK, Finn DP. Stress-induced analgesia. Progress in Neurobiology. 2009;88(3):184-202. PMID 19393288 · DOI 10.1016/j.pneurobio.2009.04.003.
• Beecher HK. Pain in men wounded in battle. Annals of Surgery. 1946;123(1):96-105. PMC PMC1803463.
• Brummett CM, Waljee JF, Goesling J, et al.. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surgery. 2017;152(6):e170504. PMID 28403427 · DOI 10.1001/jamasurg.2017.0504.
• Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use: United States, 2006-2015. MMWR Morbidity and Mortality Weekly Report. 2017;66(10):265-269. PMID 28301454 · DOI 10.15585/mmwr.mm6610a1.
• Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and nonopioid analgesics on acute extremity pain in the emergency department: a randomized clinical trial. JAMA. 2017;318(17):1661-1667. PMID 29114833 · DOI 10.1001/jama.2017.16190.
• Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150(3699):971-979. PMID 5320816 · DOI 10.1126/science.150.3699.971.
• Johnson MI, Paley CA, Jones G, Mulvey MR, Wittkopf PG. Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: a systematic review and meta-analysis of 381 studies (the meta-TENS study). BMJ Open. 2022;12(2):e051073. PMID 35144946 · DOI 10.1136/bmjopen-2021-051073.
• Hamblin MR. Mechanisms and applications of the anti-inflammatory effects of photobiomodulation. AIMS Biophysics. 2017;4(3):337-361. PMID 28748217 · DOI 10.3934/biophy.2017.3.337.