Experts: COX-2s still have role in pain care

Physicians should not be reluctant to use COX-2 inhibitors to treat pain in the short term, and they might be able to promote faster healing by addressing pain quickly and dealing with any underlying depression. These were the findings of several presentations at the annual meeting of the American Academy of Orthopaedic Surgeons last month in Chicago.

Controversy over COX-2 inhibitors broke in the fall of 2004 with the release of data linking long-term use to an increased risk of heart attack and other cardiovascular events. Two drugs in this class, rofecoxib and valdecoxib, were withdrawn from the market, and many patients who had been using them for chronic conditions were switched to other drugs.

Experts say, however, that this kind of drug still has a significant role in managing acute pain, particularly that associated with surgery.

"There's no evidence that short-term use really has any significant cardio-toxicity," said Thomas A. Einhorn, MD, chair of the Dept. of Orthopedic Surgery at Boston University School of Medicine. He moderated a panel on COX-2 inhibitors and nonsteroidal anti-inflammatories.

A growing body of evidence also shows that failing to control a patient's pain adequately might translate to more than just a bad experience for the patient. It might cause slower healing and a lower level of function over the long haul. For example, one study found that patients receiving a total knee or hip replacement who received aggressive pain control during and after the surgery were more likely to achieve an early recovery. They also were more likely to describe their recovery as easy and had little or no pain by the end of six weeks.

"All patients undergoing total hip or knee replacement will experience significant pain. Our challenge is to reduce pain to an acceptable level," said Chitranjan S. Ranawat, MD, the study's lead author and chair of the Dept. of Orthopedic Surgery at Lenox Hill Hospital in New York.

The authors hypothesize that the pain not only makes the patient less willing to participate in various activities but also might interfere with how the tissue heals around the implant.

"The theory is that pain triggers the fibroblastic response, and there's a connection between pain and function," Dr. Ranawat said.

Mental health's role

Although many researchers are studying how pain affects recovery, others are focusing on the effect of a patient's mental or emotional health. A trio of papers suggests that depression and related illnesses might cause increased use of health resources, a reduced likelihood of doing prescribed post-surgery exercises and a worse outcome from joint replacement surgery.

"Depression is associated with an increased utilization of health care resources in nonsurgical situations. It's important to understand the implication after surgery," said Patricia D. Franklin, MD, MPH, associate professor in the Dept. of Orthopedic Surgery at the University of Massachusetts Medical School in Worcester. She was the lead author of a paper looking at the association between emotional health and health care use after total knee replacement.

But researchers said that although these studies showed a strong correlation, it was unclear exactly how to address this phenomenon. Those treated for depression tended to do better than those who had not been treated but still did worse than those without mental illness. Experts say treating everyone before surgery might not solve this problem.

"Depressed patients start off worse than nondepressed patients. They get better, but they never catch up," said Victor Hugo Hernandez, MD, research director at Mercy Hospital in Miami. He presented a paper that associated mental health with the outcome of hip and knee replacement.

Authors suggest that a more effective strategy may be to detect these patients and give extra help in recovery.

"We may not be able to change their [mental health]," said David C. Ayers, MD, chair of the Dept. of Orthopedic Surgery at the University of Massachusetts Medical School in Worcester. "Perhaps they need more resources for the months after surgery." He authored a paper linking pre-operative emotional health with adherence to post-surgical exercise regimens.