Why Isn't Portugal Dopesick?

Surgery, painkillers and Portugal...

Did you watch the Hulu mini-series Dopesick? We did and were ticked off for a week. Recently my anger resurfaced while listening to the podcast Opioids in America. But rather than just being angry, I started to think. Why was I given a narcotic after surgery in the US, and only Paracetamol (Tylenol) when I had exactly the same procedure in Portugal? My inquiring mind wanted to know.

The Back Story

If you have been with me from the beginning, you know that while I am generally a healthy individual, I have had three surgeries since moving to Portugal.¹ The first, one week after falling off my electric bike and fracturing my elbow. I want to point out that the Portuguese healthcare system did not cause the delay between the accident and surgery. It was entirely my fault because I walked around for nearly a week hoping it wasn’t fractured. When I did seek medical advice the surgeon took one look at my swollen, blue arm and said “You must have a very high pain tolerance.” After the surgery, I was provided a prescription for 3 days of Paracetamol. I don’t recall whether or not it was required.

My second surgery was to fix a botched bunionectomy performed in California about one year before we moved. During the pre-operative exam, I mentioned my prior experience and the fact that I had used Hydrocodone (an opioid) for six weeks following surgery. The surgeon looked surprised.

That should not be necessary. I typically prescribe Paracetamal for a few days. — Dr Vide

After the surgery, Dr. Vide confessed that the surgery was a bit more complex than he had anticipated … several more bones were cut … a lot of screws were removed and others were inserted. As such, he was prescribing Tramadol which I could take if needed. But the prescription was only for a few tablets and shouldn’t be required after the first day or two.

The $64,000 Question

So I am left wondering…why does one receive a potent narcotic following a surgical procedure in the US, but instead receives Tylenol when that same procedure is performed in Portugal. My Google machine led me to studies showing that Americans seem to experience more pain than Europeans.

• “Evaluation of the pain PROs revealed that European patients reported much lower Worst Pain on the first day after orthopedic surgery than American patients. The mean Worst Pain (± SD) for Europeans was 5.4 (2.5) but for Americans, the mean was 7.4 (2.7), p < .0001, a large effect size. Europeans also reported significantly less emotional discomfort, less interference of pain with activity, and lower Least Pain. Nonetheless, 98.3% of American patients received opioids on the ward on the first postoperative day compared to 70.2% of European patients, and 41.1% received regional analgesia on the ward while 15.9% of European patients received regional analgesia (both small effect sizes). Overall, the results are clear in demonstrating much better pain control in the ensemble of European countries as compared to the United States.” — Quality of postoperative pain management in American versus European institutions, NIH National Library of Medicine

• “…there is evidence that Americans are in more pain than citizens of other advanced, and even not-so-advanced, countries.” — Unhappiness and Pain in Modern America, National Bureau of Economic Research

• One article from The Atlantic summarized several studies and concluded that while there are contributing factors such as obesity and the over-prescribing of painkillers in the US, it is “all in our heads.” — America Experiences More Pain Than Other Countries, The Atlantic

Now before you yell and scream and tell me there are people that suffer from measurable chronic pain…I agree! I am not suggesting it is all in anyone’s head. I cannot measure another’s level of pain! I am not calling you or anyone else “a wuss”. I am just suggesting that following surgery, there seems to be (i.e. my experience has been and scientific studies indicate) that pain management is handled differently here. There must be reasons why:

The United States makes up 4.4% of the world's population, and consumes over 80% of the world's opioids. — Opioids — Perception of Pain, MN Department of Health

So What Do You Think?

Could it be that physicians offer a different expectation of what one will experience following surgery, and as a result their patients perceive their level of discomfort differently? Is it possible that the pace at which life occurs in the US, affects the amount of time surgeons take…the time provided by other caregivers following surgery? Is a certain degree of discomfort expected and accepted in the rest of the world? Is the pharmaceutical industry to blame?

I am not certain there is one simple answer. But I am certain my post-surgical pain experience was very different here than in the States. I only took the Tramadol for one day following surgery here, versus 6 weeks of Hydrocodone in the States … and last I checked physically I am the same person.

Por favor, diga-me e volte na próxima semana, beinjinhos

Nanc

1. Here’s a list of additional posts on medicine & dentistry in Portugal: Dentistry in Portugal, Waiting is the Worse Part, and The Cost of Portuguese Medicine.