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No More Pressure to Prescribe

By Ilvy H. Cotterell, MD

When I was a resident, I recall prescribing upwards of 50 pills of narcotics for routine soft tissue procedures, as this minimized the likelihood of a phone call that night from the patient for pain related questions.  At that time, I did not consider the potential for actually doing harm by the patient, increasing their risk for developing an addiction and abusing these medications, or selling them to others who may go on to develop an addiction.

Once starting my own practice, I often times did not see the need for any opioids to be prescribed, but felt pressured to do so, in order to avoid an unhappy patient, or emails from our patient relations department about a patient complaint about their pain not being adequately addressed. With the pain score being charted as “the fifth vital sign”, it equates not treating the pain number on the smiley face chart to ignoring a hypertensive crisis, high fever or hypoxemia. Many times patients rate their pain as a 10/10 despite comfortably eating a snack and texting on the phone during their clinic appointment. But they were essentially supported in demanding more pain medications, similar to getting blood pressure medications for hypertension – and if their request was not met, justified a bad rating or online review, potentially negatively affecting a physician’s reputation.

It has taken many lives to bring attention to this crisis, but the recent dedication to public education and widespread efforts to increase public awareness about this nation’s opioid abuse problem has brought many positive changes to my practice. The development of guidelines for postoperative pain prescriptions depending on the type of procedure, along with the vast evidence that narcotics are not necessarily the best medication for many procedures – especially in hand surgery – has significantly affected my postoperative pain control regimens over the last 2 years.

Having recently had my own carpal tunnel release, I now know first-hand that the post-op discomfort is nothing a few NSAIDs can’t handle. We have established clinical guidelines and policies on prescribing narcotics, which is visibly displayed for patients to see. I no longer routinely prescribe anything for simple soft tissue procedures. Of course there are exceptions. And of course for complex, bad injuries or painful surgeries I still prescribe narcotics, and will write for refills within reason. But what has changed for me, is that I no longer feel the pressure to prescribe narcotics if I do not believe it is indicated, despite knowing the patient will be angry or upset, because I know that ultimately it is in their best interest.

Comment (1)
William H Bowers
December 13, 2018 11:38 pm

Glad you pitched in here Ilvy. The happy face /sad face chart and the “fifth vital sign” were well meaning but wrong ways to deal with the management of post surgical pain.
We have to help our patients and ourselves out of this hole we dug.


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