Blog — Notes of a Plastic Surgeon

Welcome to my blog. I am a plastic surgeon in Seattle and have been in private practice since 1991. I've seen more than a few interesting faces and cases through my years spent in the exam room, the operating room and the emergency room. And I have an opinion on just about everything relating to plastic surgery (and a lot of unrelated stuff). If you like my blog, let me know. Thanks for reading! Lisa

The Opioid Crisis and the Post Surgical Patient

It seems that not a day goes by when we are not hearing more bad news about America’s opioid crisis.  And with good reason.  This crisis is ruining the lives of the abusers and those who love and depend on them.  A recent photo  spread in the New Yorker Magazine laid it all out in clear and agonizing black and white. So what is a surgical practice like mine doing to respond to this crisis?

Just about every operation I do causes a significant amount of postoperative pain for which I usually prescribe an opioid.  In the 26+ years I have been in practice, I have seen only a few patients who I felt were getting habituated to the medication I prescribed.  And in those cases, I take a straight forward:  “I am worried about your narcotic use” approach.  To my knowledge, I have not had a surgical patient become an addict. 

It is a fine line we have to walk between over prescribing and under prescribing.  Most patients are seen maybe 3 – 7 days after surgery for dressing changes, drain removal and general checking in.  We try to prescribe enough medication to last until that first post op appointment.  If a patient runs out of their narcotic pain medication, we cannot phone in a prescription.  The patient or their caregiver must come to the office to obtain a “hard copy”.  This can be a real burden for the patient.  Often we will write an additional prescription for the patient to fill in the event they run out prior to an office visit.  We emphasize that if the prescription is not used, it should be destroyed.  Likewise, all unused medication does not belong in the medicine cabinet “just in case”.  It should be destroyed or returned to the pharmacy for proper disposal.  There is evidence that diversion of narcotics is a driver in addiction.

We also try to help with pain control with non-opioids.  Almost all tummy tucks get an On-Q pain pump that helps with postoperative discomfort for the first three days after surgery.  We use instillation and injection of long acting local anesthetics to take the edge off of surgical pain.  And once a patient is about 5 days out from surgery, we do out best to get them onto an NSAID and off their prescription pain medication.

Research has shown that it is when opioids are used for chronic pain conditions, patients are much more likely to fall into habituation and addiction.  Opioid use for acute pain (like post operative pain) usually is temporary and most often discontinued by the patient with very few problems.  Most of my patients do not like the way they feel on narcotics and are anxious to get off.  An occasional patient really likes that loopy and foggy feeling that narcotics provide and those are the ones that we worry about.  Again, I take a straight forward approach “You like this medication way to much.  Time to get onto an NSAID.”

On thing that has really changed with the new laws regarding phoning in narcotic prescriptions is the steep decline in bogus phone calls to the doctor on call from drug seeking individuals.  When I was in a large call group years ago, it was not unusual to get one or more of these bogus calls on a weekend.  These calls could be very troubling for the doctor on call because it was often difficult to sort out a legitimate patient and a bogus caller.  What is worse:  phoning in a script for Vicodin to be abused or diverted or not providing relief to a postoperative patient?

One thing everyone can do to help fight this crisis is to take a look in your medicine cabinet.  Are there unused prescription pain pills in there?  If so, take them to our nearest pharmacy for disposal.

Thanks for reading.  Dr. Lisa Lynn Sowder

 

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