by Vik Reddy, MD, MHSA, FACS
“The surgery went well, and Ms. Brown’s immediate postoperative course was without any complications. Three weeks afterwards, however, she developed an opening along the abdominal incision. The wound had separated, and the mesh I had placed was exposed. My hope was to try and get her through this complication without having to remove the mesh. The one bit of good news was that the tissue used to recreate one of her breasts was alive and healing nicely. Ms. Brown took the news in stride, but she did ask for a refill of her pain medications: Percocet, Valium, and Oxycontin. She was three weeks out from her operation, and, while it did seem like a lot to me, I rationalized her needing the medications because of the complication. I filled out the three prescription sheets, and said I would see her next week.”
The above excerpt is from a non-fiction article I wrote entitled “Physician as Enabler” published in Intima: a Journal of Narrative Medicine. In the essay, I describe how a patient whom I performed a TRAM flap on continued to request prescription narcotics weeks after her surgery was done. Because she developed a complication involving her abdominal donor site, I was hoping that I would address her dependence on narcotics after I had successfully treated her wound. Unfortunately, she eventually left my practice with an abdominal wound and a narcotic addiction.
According to the CDC, the rate of deaths attributed to opiates has quadrupled since 1999, and 78 Americans die every day from opiate overdose (1). These statistics have the unfortunate effect raising awareness, but can also lead to a sense of helplessness, including the medical community. Great work in combating prescription drug abuse, however, is occurring all over the nation. As one of the counties with the highest rate of heroin deaths in Michigan, a group of community leaders has partnered with hospitals, schools, police departments, and social workers to combat the opiate epidemic through a number of initiatives including offering disposal centers for unused narcotics, giving police officers training on how to use naloxone, promoting treatment for addicts, and education physicians (2).
I hope that sharing my story about a patient who became addicted to opiates under my care will allow physicians, including plastic surgeons, to see that a patient can develop an addiction insidiously. Unfortunately, like many physicians my age, I went through medical school and residency holding onto such dogmatic ideas as “pain is the fifth vital sign,” “pain is unnecessary,” and, probably the worst, “pain medication does not create addicts.” My father, a plastic surgeon, trained in the 1980s has always been parsimonious when dispensing pain medication. He did not change his practice when everyone else began to. I used to blame it on his not understanding how medicine was currently practiced. Like many things in medicine (and not related to medicine), time has proven him right.
I do believe that plastic surgeons may be at a higher risk of falling into the same trap that I did with my patient. Inherently, plastic surgeons are people-pleasers. Altering the external appearance of a patient, either for cosmetic or reconstructive purposes, creates a dynamic fundamentally different from other physician-patient relationships. As a patient stares at their scars, or is asked to wait for the swelling to resolve, the impetus to allay one of the patient’s concerns, namely pain, is strong.
As I did not offer any suggestions in my article, I want to end this post with some guidelines on prescribing opioids from the Institute for Clinical Systems Improvement (3):
• Avoid prescribing more than three days supply or 20 pills of low-dose, short-acting opioids, unless circumstances clearly warrant additional opioid therapy
• Never prescribe long-acting/extended-release opioid preparations for acute episodes of pain
• Shared decision-making; patient must be educated on opioid risks and benefits to make an informed decision
• Review safe driving, work, storage and disposal
• Maximize appropriate non-opioid therapies
REFERENCES
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- http://www.cdc.gov/drugoverdose/epidemic/index.html
- http://www.operationrx.com/
- https://www.icsi.org/_asset/dyp5wm/opioids.pdf
PRSonally Speaking 