Pain Guided Healing: Something We Should All Know About.

Pain guided healing is also called common sense: “Don’t do what hurts.” Surgeons tend to focus on what kind of pain medication to prescribe after surgery. It helps to talk to patients about how to manage their postoperative pain in words they can understand. This is a conversation that many patients would love to have with us. All we need to do is bring up the subject with them. The goal of this editorial is to suggest that you consider using the types of words I have found to be successful in speaking to patients. Many will gladly follow pain-guided healing, get off drugs quickly, and avoid unnecessary complications if you follow this approach. (See Video [online], which displays talking to a patient about pain-guided healing during finger fracture K wire fixation.)

Video 1.

This video displays talking to a patient about pain guided healing during finger fracture K wire fixation.

I like to start the conversation with general advice on keeping the operated anatomy elevated and quiet for the first 2–3 days to let internal clotting get solid, let swelling come down, and provide the opportunity to get off all pain killers before starting activities.

I move to asking what they normally take for pain if they have a headache. Usually, the answer is some form of ibuprophen or acetaminophen. I reassure them that that is all they will need after this operation if they keep quiet for 2–3 days until they are off all pain killers. Most understand and nod wisely when I say: “We did not spend 2 billion years evolving pain because it is all bad for us…. It is your body’s only way to say to you: ‘Hey, would you quit that? I’m trying to heal in here and you are screwing it up! Stop that!!!’” Most patients smile, and then I add: “That is a little voice in your head that you want to listen to, but you can’t hear it with Advil in your ears! It’s OK to take Advil for a few doses to get rid of the sting of the cut when the numbing medicine wears off after your surgery. If you keep your hand/face/chest quiet, usually the sting of the cut is completely gone after a day or two. The pain of the cut quickly becomes the pain of ‘Gee doctor, now it only hurts if I put my hand down or when I do things with it.’ As soon as you get into the pain of ‘It only hurts if I put my hand down or when I do things with it,’ you stop taking all pain killers and listen to your body. Just don’t do what hurts. It’s called pain guided healing. It’s also called common sense.” Most patients nod wisely again and say that common sense is not common enough. Patients love the sense of control and empowerment that comes with this approach.

I tell them that if they ask me 200 questions that start with: “Dr. Lalonde, when can I…?” the answer will always be the same: “When it doesn’t hurt.” “Dr. Lalonde, when can I drive? When can I do yoga?” The answer is: “When it doesn’t hurt to do yoga.”

Clearly this approach does not apply to patients who are on pain killers all the time. Those patients will likely stay on their medications and may well require more. I still try to broach the subject of pain-guided healing, but they are frequently unreceptive. The good news is that more than half of our patients are “normal” people who are not on pain drugs all the time.

I have found that this approach works well for breast reduction/augmentation patients (see Video in Ref. 1).[1] I have not written a narcotic prescription for those operations, most hand surgery, and most facial soft tissue surgery for many years unless the patients are chronic drug takers. I tell patients to start with 400–800 mg of ibuprophen depending on the extent of my dissections. I follow that with the option to add 1 g of acetaminophen after 30 minutes if they are still too uncomfortable. I explain that those two drugs work in a different way so they work well if taken at the same time. This combination usually works very well if they keep their operated anatomy elevated and quiet.

There is ample level I evidence that narcotics are not superior to over-the-counter medications in simple breast[2] and hand[3-6] operations. In the first 15 years of my practice, I followed a common course of a routine postoperative prescription of acetaminophen/codeine combination for all patients, with no written or oral advice on how to take the medication. More importantly, I never discussed with patients how and when to STOP taking the prescription. Now that I have the conversation with them, my patients’ experience is so much better. They get no nausea and vomiting with this no opiate, no gabapentin approach. Their return to normal activities is faster. They have fewer complications because they are listening to their body and heeding its advice. I often end our operative meeting with: “Your body is much cleverer than I am. It will tell you what to do and what not to do. You only need to listen to it.”