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On my return flight from ISAKOS’s Congress in Cancun, I watched the inflight movie, an American family drama called ‘Ben is Back’.1 Ben is a teenage addict, and his mother—played by Julia Roberts—is Christmas shopping. She bumps into Ben’s old doctor, Dr Crane, who seems to be drifting into senility. She asks him: “Do you remember my son Ben?” Apparently, he does not, but she continues: “When Ben was 14 he had a minor snow-boarding injury, and you prescribed painkillers. I was worried, but you told me they were not addictive, and you kept upping the dose. Well, he got hooked, and it has f*****d up his life. So you can pretend you don’t remember, but I won’t forget. I hope you die a horrible death! Merry Christmas.”
Pain is the most common reason patients visit orthopaedic surgeons. Patients are seeking treatment to get rid of their pain. And we are very good at doing this, with our advice and surgical interventions.
We also prescribe painkillers, as part of our conservative treatment, for fracture care and postsurgical pain.
But some 70 000 people die every year in the USA from overdoses, and the majority of deaths are from opioid painkillers.2 How did it get this far?
Let’s consider some basics
Nociception is a neurophysiological mechanism by which the central nervous system is alerted to actual or potential tissue damage on the periphery. Nociception can either be ‘superficial’ or ‘deep’, depending on the stimulus location. Superficial nociception derives from the skin and is usually short and sharp. It transmits quickly, along myelinated A-delta fibres at 4–36 m/s. Deep nociception derives from ligaments, tendons, muscles, bones and so on, and is usually dull and aching.
But pain is also influenced by psychosocial factors, which can ameliorate pain—or aggravate it. Some cultures, like those of …
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