Opioid Epidemic: How Can Plastic Surgeons Provide Relief?
In 2017, 70,237 drug overdose deaths occurred in the United States of which 47,600 or 67.8% were related to opioids. Thirty five percent of these opioid related deaths were attributed to prescribed medications 1. While the overall prescribing rate in the United States has been declining since 2012, the amount of opioids (in morphine milligram equivalents) prescribed per person is still approximately 3x higher than in 19992.
In 1996 the American Pain Society introduced the concept of pain as “the fifth vital sign”3. A few years later the Joint Commission and the Veterans Health Administration stressed that pain needed to be regularly assessed in all patients, pain is a subjective measure, and that physicians must accept and respect patient self-reporting of pain4. The promotion of pain medications ensued lending to over subscribing and abuse by profit seeking pharmaceutical companies and some unscrupulous medical professionals. Studies and opinions have questioned the value of the concept of “the fifth vital sign”4,5,6 and in 2016 the AMA dropped the terminology7.
As surgeons, we are faced with the necessity to provide adequate relief to our patients who either present with discomfort (pain) or develop discomfort as a result of our procedures. The issue at hand is how can we efficiently provide adequate relief without further contributing to the existing opioid epidemic? The days of arbitrarily writing prescriptions for any number of narcotic tablets with multiple renewals have long since passed. Many states are increasing demands on prescribing practices to assure that patients are not receiving excessive quantities of narcotics.8 How then, do we moderate the use of narcotics, particularly in light of the fact that most medical school and residency education programs inadequately focus on pain management? Until recently, there has been relatively little promoted on the topic in plastic surgery presentations, seminars, symposia and our literature.
As noted in the articles and their references included in this thematic edition of Aesthetic Surgery Journal, aesthetic surgeons have had an interest in alternative methods of dealing with perioperative discomfort for some time. This interest has been stimulated, in part, by the desire to reduce PACU time for outpatient and office based surgical procedures while improving patient comfort and satisfaction. Concerns, such as but not limited to additional time needed for the administration of adjunctive anesthetic nerve blocks and/or the added expenses associated with patient prescriptions and facility medications, may perhaps mollify some enthusiasm for modifying long standing routines. These and other obstacles to the reduction of opioid consumption in the perioperative period can and should be clinically and scientifically debunked.
It is our hope that, by focusing attention on this topic, a better understanding of the non-narcotic approach to perioperative management is gained and additional discussion and research results. It is a topic that we as physicians and surgeons need to come to grips with before legislators and lawyers become further involved in the practice of medicine.
1Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G, “Drug and Opioid Involved Deaths- United States 2013-2017. Morb Mort Wkly Rep. EPub: 21 Dec 2018
2Centers for Disease Control and Prevention. Vital Signs: Change in Opioid Prescribing in the United States. 2006-2015 MMWR 2017: 66(26): 697-704
3Pain: Current Understanding of Assessment, Management, and Treatments, The Joint Commission on Accreditation of Healthcare Organizations; The National Pharmaceutical Council, December 2001, Sec II:21-29
4The fifth vital sign: A complex story of politics and patient care, Mandell, Brian F, Cleveland Clinic Journal of Medicine. 2016 June; 83(6):400-401
5Measuring pain as the 5th vital sign does not improve quality of pain management. Mularski RA, White-Chu F, Overbay D, et al., J Gen Intern Med 2006; 21:607–612.
6Is Pain Really The 5th Vital Sign?, Articles, Doctor's Voice, Pain Management, Psychiatry, Skeptical Scalpel, Physicians Weekly, Oct 28, 2013
7AMA Drops Pain as Vital Sign. Anson, P., Pain News Network, June 16, 2016.
8Initial Guidance on House Bill 2174(HB 2174), Texas Medical Board, August 30, 2019.
Norman H Rappaport, MD, DMD, FACS
Houston Center for Plastic Surgery
6560 Fannin Street, Suite 1812
Houston, TX 77030
713-790-4500
[email protected]
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Enhanced Recovery After Surgery: The Plastic Surgery Paradigm Shift
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The Opioid Crisis: What Must Aesthetic Surgeons Do About It?
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Book Review: Perioperative Pain Management for General and Plastic Surgery
Norman H Rappaport, MD, DMD, FACS
