Pain control: Let’s rethink our prescribing habits
When it comes to prescribing narcotics to control pain, I think I owe someone an apology. I can honestly say I didn’t mean to cause a problem. Further, I’d argue that I was practicing what was considered at the time the normal boring standard of care. But if you listen to the news recently, or even the U.S. Surgeon General (I assume everyone received his August 2016 letter), you’d think I was Josef Mengele.
I attended the University of Michigan Medical School between 2003 and 2007, and one of the required classes during the first years was a multidisciplinary class. It was a great break from time spent memorizing the Krebs cycle and allowed us to think that we were practicing medicine. Once a week, we sat down in a small group setting and talked about various clinical situations.
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It was in that class I was “taught” that narcotics were not addictive and that it was my responsibility as a physician to control pain. Hence, as I entered residency, I was primed and willing to write narcotics. Most of the attendings in my residency at the University of Iowa seemed to agree. But one did not.
Richard D. Williams, MD, was right, as it turns out. Dr. Williams, as many of you know, specialized in prostate cancer and performed thousands of open radical retropubic prostatectomies. I only had the privilege of scrubbing with him once during a prostate as he stopped operating when I was still a junior resident at the University of Iowa, but I remember a wise and confident surgeon constantly pimping one of the senior residents during the case. The only thing I did on that case was cut suture, and I wasn’t sure if he even realized I was there until the end of the case when he turned to me and reminded me to find him the following morning to take him to round on “our” patient.
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Early the next morning I walked my chairman to see “our” patient. I had been on call that night and had poked my head in a few times to check on this particular man, as I had no intention of messing up my first real encounter with Dr. Williams, whom all the residents simply referred to as “Boss.” The patient had abdominal pain near the incision overnight so I had increased his pain medicine from tramadol, which was on Dr. Williams’ pathway to acetaminophen/oxycodone (Percocet). Of all the decisions I made overnight, that one seemed the most straightforward.
Boy was I wrong. When Dr. Williams learned that I gave one of his patients Percocet, he spent the next 10 minutes lecturing me on the dangers of narcotics and how most pain can be controlled with non-narcotic methods. I left that interaction puzzled as I remembered well the lessons I was taught in medical school and was unsure how to proceed. I remember talking to the other residents and learning about Dr. Williams’ preference, but given that this was one of my few surgical interactions with the Boss, my own prescribing pattern when I graduated residency and started work in the real world were markedly different.