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.