Most surgeons prescribe post-op narcotics to treat pain. The typical plan is a short course of narcotics followed by non-narcotic medication or no medication at all. I am not referring to complex pain or chronic pain. I am talking about a patient who in theory is not on narcotics when they see you, has surgery, and then will be on a week or two of tapered medication.
A plastic surgeon I respect asked me to eyeball a template document he started asking his patients to sign. It states, among other things:
We request your agreement to abide by these guidelines:
- We will prescribe narcotic pain medication in a responsible manner to help alleviate pain experienced by our patients as a result of a procedure at our clinic. Unrelated pain, chronic pain and other issues should be managed by a pain management specialist.
- No narcotic prescriptions will be replaced if lost or stolen.
- No narcotic prescriptions can be refilled by phone, in compliance with state regulations.
- All narcotic prescriptions must be printed on tamper-resistant paper and can only be given during normal business hours. This means that adequate planning is important, especially before weekends and holidays.
- It is the patient’s responsibility to:
- Notify us of any prior history of addiction or drug abuse. This will help us manage your pain more effectively and safely.
- Notify us of any prescriptions that you receive from another physician.
- Take medications only as prescribed, avoid any other narcotics while taking the prescribed medications, unless clearly communicated and agreed to with your doctor.
- Avoid driving or performing any hazardous activity while taking narcotics.
- Avoid ingesting alcohol or recreational drugs while taking narcotics.
- Notify us promptly of any possible side effects, or if you feel that you are over-medicated or under-medicated.
There are other details in that agreement. But those are the salient points.
At first I thought, what’s the point? Every patient will sign on the dotted line and it will change nothing. He’s not seeing chronic pain patients or managing an addiction practice.
Then I changed my mind.
Imagine a patient with a history of substance abuse comes to your office. Clean now. But, struggled to overcome a serious problem in the past. He says nothing about the history. You operate on the patient. He gets one week of narcotics for the expected post-op pain. Then one more. You never see him again.
Unbeknownst to you, he’s doctor shopping. His habit is back. He overdoses.
The Board starts investigating. The patient’s wife hires an attorney. You’re now in the crosshairs.
The question you never want hear:
“Doctor, did you even ask if the patient had a history of substance abuse?”
If you had such an agreement with the patient, he might have admitted to the history; and the two of you could have figured out a better post-operative plan of action. Or, he might have lied and nothing would have changed – except your answer to the Board and plaintiff’s attorney.
So, I’ve changed my mind. I think such a template does make sense. It’s like a parachute. If you don’t have it when you need it, you’ll never need it again.
Most physicians and surgeons have an “entry-note” that all new patients fill out during the time they are in your reception room. Every doctor I know (and now dentists as well) asks questions about PRIOR “recreational” drug use or history of problems with drugs, narcotics, prescribed or otherwise…including alcohol. Presumably you or a staff member will read that entry form before you see the patient.
If you see a drug/alcohol problem entry, your exposure index should hit the roof. Of course patients can and will lie. Any doctor who is sued after a bad post-operative experience with narcotics should REVIEW the patient intake form to see if their patient did lie. Don’t discount family members. They will often disclose to you, even if the patient does not. It never hurts to ask them outright.
An outright lie on an intake form will help make your case much more defensible. A copy of it faxed to plaintiff’s attorney might be enough to fix it on the spot. Plastic surgeons are in a peculiar place because the highest percentage of their cases are elective.
If I were to review this form, I think I would add more to it. For example notes about issues of pain that is not amenable to narcotics, as well as the excessive, unrealistic expectations that narcotics “cures” all pain. Surprisingly, some patients believe that. Your patient should be counseled not to expect that ALL pain will be removed.
For our patients we discussed methods of self-hypnosis and “suggestion” to combat pain. This would include:
1. Allocating 1 hour/day to “feel sorry for yourself.” Cry, swear, be a “child,” be upset, be angry, etc. But after that hour you had to retreat to adulthood. This means watching TV, playing board games, talking politics, anything else to keep your mind off of yourself. You would have to wait until the next day to experience “feeling sorry for yourself.”
2. Use tricyclic anti-depressants to reduce the need for narcotics. Everyone who has severe pain will get just a little depressed. Narcotic analgesics do not treat depression. Sometimes they actually exacerbate depression.
3. Use self suggestion to treat your pain: Look into a mirror every hour and repeat: “I will have much less pain today. I am getting better every day. The swelling is going down. I am relaxed.” Say this out loud. Be enthusiastic.
Don’t discount this as nonsense. I do it myself when I have surgery. It is surprisingly effective. Take full advantage of the placebo effect. It is real. Even for you. Despite your education, you still have a mammalian nervous system.
4. Build up a steady blood level of non-narcotic analgesics and if necessary, muscle relaxants. But your patients must be careful. Muscle relaxants and alcohol can very easily result in death from respiratory depression, as much or more than narcotics. Surgeons who operated through muscle tissue can find good benefits from muscle relaxants, for patients who have spasms.
5. Save narcotics for times of need of sleep. Your patient can often keep themselves “occupied” in other ways during the daytime.
6. Counsel your patients not to have unrealistic expectations from narcotics. Even with narcotics, most patients will experience soreness and pain. But it gets better every day in the vast majority of cases. Being completely pain free just doesn’t happen.
If I were writing the above note, I would include at least SOME alternative methods to control pain to show the patient that you “understand and care about them.”
Finally there is the “flake” index. You leave the treatment room and your toes are curling after speaking with the patient. You don’t trust them. It’s just a really bad feeling you have…
Go with your feelings. Most of the time you are right. Maybe you should refer them out…
Michael M. Rosenblatt, DPM
Will add “Any history of narcotic or substance abuse?” to our preoperative checklist. Thank you.
As a consultant to surgical specialists, I found the form very relevant and useful. However, I would share that in my experience, after orthopaedic and plastic surgery, I was prescribed 30 oxycodone tablets, after explicitly saying, “I don’t like the GI side effects…small number please!”
I was told “not to worry it’s not expensive.” That’s NOT the point. The point is that I now have a medicine cabinet full of these pills. And, what if I was someone with a history of problems? One would be sorely tempted, wouldn’t they? Or I suspect some people sell the pills. More trouble there. By the way, in conversations with friends, more than half report a similar experience with large, unnecessary prescriptions. My hunch is that the doctor didn’t to be interrupted for a refill request.
I agree and have used Dr. Rosenblatt’s techniques personally. There is an excellent book and tape, “Prepare for Surgery and Heal Faster” by Peg Huddleston who works with patients in NY. She has guided imagery examples.
Anyone who doesn’t want to cooperate and try may have another problem.
Thoughts?
I think the notion of a narcotic contract is important. The narcotic contract that I had with my patients in a chronic pain practice was 6 pages long. Did patient’s read it? We forced them to sit down and read it. Some left the office without signing. We were also required to run a state electronic narcotic record on the patient before prescribing. If we were doing pain procedures on the patient we would have the patient do a urine triage drug screen. No screen, no procedure, no prescription. We tested by indication and suspicion among other reasons. We also repeated the query of the narcotic record at 3 month intervals for our entire practice. We weeded out quite a few patients along the way.
We were not as stringent before giving patients anesthesia, but often wondered about tolerance issues that popped up on numerous occasions. Is there a perfectly acceptable procedure for this? Probably not. If patients told us that they were on chronic benzodiazepines, and on carisoprodol (Soma), that was a flag to us that they were also on narcotics (the triple). Chronic antidepressant use was also another flag for potential narcotic abuse.
I would suggest that if a history of drug use is detected that the patient be referred to a pain specialist for consultation before the procedure regarding post op management of pain. An agonist antagonist narcotic medication post op may be appropriate for those with drug addiction problems.
Judicious use of acetaminophen, local anesthetic, nerve blocks (as appropriate), and if permissible for the surgery, single doses of ketorolac, possible intraoperative use of small doses of ketamine, and possible single doses of steroids intraop may all mitigate the need for post op narcotics. All of those may help dodge the narcotic issue in whole or in part.
Would the licensing board ask what was done to mitigate the need for narcotics? Perhaps, but not likely. Nevertheless a prudent physician would seek multimodal pain relief strategies in these patients. More complex certainly. It is much easier to just reach for a prescription pad, and put one’s head in the sand. However the narcotic abuse epidemic necessitates different strategies to keep our patient’s and our licenses safe.
What if the patient took all of the pain medication immediately after filling the prescription, and overdosed, because they were no longer narcotic tolerant?
What if the patient took some or all of the pain medication the day after surgery and drove to the surgeon’s office, and while driving, hit a young child? DUI and vehicular manslaughter, but is the family going to go after the prescribing physician? What about the adverse publicity and scrutiny from the public and the licensing board that results. How will that affect the plastic surgeon’s practice? Better to ask these questions in advance and be pro active, rather than reactive. Yes it takes time, but far less than the defense costs in time and money after the fact. We live and work in different times, and things are not what they used to be.
Not mentioned in Lee’s excellent post (a physician who practices on chronic pain syndrome patients) is the issue of PHYSICIAN CHOICE. All of the efforts that you wish to take to avoid problems with your practice and medical boards are meaningless unless you have “physician choice.”
You must have financial/practice autonomy to reject patients who are risky to you. The factors that mitigate against autonomy are rarely mentioned in risk-prevention articles. They include some of the following:
1. Multiple divorces and family dislocation, resulting in the required financial maintenance of more than one family/spousal unit.
2. Physician drug, alcohol or addiction problem
3. Poor physical health that requires dropping of practice hours
4. Multiple malpractice suits that result in an enormous time demand
5. Major family disability
6. Aggressive employer who requires that you take excessive risks to maintain their group practice financial goals
7. Inadequate risk control planning and referral possibilities
8. Student/residency status that removes choices from your own control
9. Excessive personal spending to “make-up” for lost time
10. Spousal hyper-shopping to prove that you are in an upper social class
11. Obama-care requirements for base-line number of patients seen per quarter as dictated by your employer contracts
12. Multiple children in very expensive private universities who regard you as a “walking credit card.”
These are just a few factors that mitigate against your personal control of the patients you see. There are others. Most do not “go away” by themselves. Your personal life can and will affect your practice life. It is a myth to think that you can separate them.
If you are interested in learning how to avoid these (and others), I respectfully recommend you look up the “Karpman Drama Triangle” on the Internet. Your goal is to avoid entry into this particular behavioral context.
Michael M. Rosenblatt, DPM