In Praise of Opioids, Part 2

 

 

 

 

Long-time readers of my blog will recall that I broke my leg – tibia and fibula – around six years ago. The point of the post was mainly to get to talk about my medical ailments, which I love, and that opioids, when used correctly, can be a huge blessing. I described how EMS personnel, on the way to the hospital, gave me a dose of fentanyl. The relief of intense pain was so miraculous.

Well, now I get to talk about my latest medical adventure.

I had a tibial intramedullary rod placed when I broke my leg. It worked beautifully and allowed my broken leg to heal much more quickly. I was ultimately able to get back to my usual activities after what could have been a devastating accident, had good medical treatment not been available.

But starting a few years ago, I had some swelling right at the middle of the tibia, with some pain. I went back to see the orthopedic surgeon, who X-rayed it, and said there was a bone callous forming there due to irritation from the tibial rod. He said he could remove the rod, and that would take care of the problem.

I asked him how big of a deal it was to remove the rod, or “nail” as it’s sometimes called, and he said, “Oh, about as much as putting it in.” That was enough for me to decide against surgery. Well, I also made the mistake of watching YouTube videos of removal of tibial intramedullary nails. Yikes. Let me just pause to tell readers that if you have an upcoming surgery, DO NOT Google or YouTube your procedure. It’s a bell you can’t un-ring.

Over the last few years, after moving to the country, I’ve been much more active, and pain at this area of my leg has bothered me more and kept me from being as active as I’d like. So, this summer I got fed up, went back to the orthopedist, got my surgery scheduled and had it done yesterday.

I was confident I could handle any pain after the surgery, since it certainly couldn’t be as bad a breaking a leg, right? Only as soon as I woke up in the Recovery Room, I had intense pain from my knee down, and started groaning and mumbling. The nurses were attentive and asked if I needed something for pain. I said yes. I’m no martyr. I had one injection of hydromorphone (Dilaudid) and it relieved all pain. I think I had one more injection of the same about a half hour later and didn’t need any more. By that time, I was awake and eager to get out of there.

Thankfully the surgeon injected the incision areas with Marcaine, a long-acting medication similar to Novocain that we get at the dentist. My leg felt numb, but that was good.

I really haven’t had much pain since leaving the surgical center. Of course, my leg is sore at the places where the screws were removed, and my knee is sore, where they withdrew the rod.

My biggest problem has been bleeding. I didn’t notice anything on the ride home, since I was drowsing in the back seat with my leg elevated on two pillows. Then when I got home, I noticed blood soaked my sock, through the wrap they’d placed.

I went to my recliner, got the two pillows, and slept, with my leg extremely elevate. I still felt a little goofy from either anesthesia or the Dilaudid, or both. I slept for a few hours, then woke to find the pillows covered with blood. In fact, the whole lower dressing was soaked, and I had to remove it, despite directions that say to leave dressing in place for 48 hours.

There was a stream of blood coming from the lower leg incision, where screws had been removed. I got some gauze and held pressure on the area with a bag of frozen corn, and the bleeding slowed to an ooze, then eventually to drops. It took nine hours to get this bleeding to stop.

As a physician, I do understand that a little bit of blood looks like a lot of blood, when it’s your blood. I put off calling the 24-hour number, thinking I was overreacting, and that the person I talked to would tell me to hold pressure, keep it elevated, and put ice on it. Still, by 10pm, I was worried enough to call, estimating I’d lost about a unit of blood.

A very nice physicians assistant returned my call, listened to my detailed report, and said if it was still bleeding in the morning, come to the Urgent Care. He also suggested elevation, pressure, and ice.

Eventually, I was so tired and sleepy that I put loads of gauze around it, replaced the pressure bandage and hoped for the best. I went to bed.

So far today, all is well. If there’s bleeding under there, I’m blissfully ignorant of it, and at least it’s not as bad as yesterday, when it soaked through the dressing.

I was given a prescription for hydrocodone, but I don’t think I’ll need it. I just took a few Tylenol and all the soreness is gone. I will keep my leg elevated, which I believe does more than anything to assist in healing, and gradually get back to normal.

Again, I think how grateful I am to have health insurance, and to have access to a great orthopedic surgeon. I feel blessed to have had good anesthesia throughout the procedure and in the recovery room, when my moderate pain was immediately addressed. I’m grateful I was given the option of taking post-operative opioids, even though I don’t plan to fill the prescription.

Yesterday I started to wonder if one of my patients, having the same procedure I had, would have been treated any differently. I hope not. Quite often, I must advocate for my patients on medication for opioid use disorder and tell their surgeons or providers that even though patients are taking a maintenance opioid, they still need short-acting opioids for acute pain situations. I hear – all too often – that patients prescribed buprenorphine or methadone are treated with judgmental attitudes, and this sort of bias has no place in modern medicine. I hope all my patients will be treated as well as I was treated yesterday, when they have medical events.

Opioids are a godsend, when we use them in the right way. The key is to use good judgment, and not to prescribe too long of a course (something that the NC STOP Act addressed) and get dependable family or friends to help a patient with opioid use disorder manage an opioid prescription for acute pain.

I’ll keep you updated with my progress. You know I will, since I love talking about my medical ailments, which are thankfully very few at this time.

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9 responses to this post.

  1. Of course someone with an Opioid use Disorder would have been treated differently 9 times out of 10. Which is why protecting and preserving 42 CFR Part 2 is so important. We are in the fight of our lives. Until stigma is eliminated and the general medical profession understands substance use disorders and their treatment confidentiality is a must. It’s a patient’s right to decide whether or not their treating physician can know about their diagnosis. And patient after patient across the nation reports they WANT to tell their treating physicians…if they have rapport and can trust them. The ball is in the court of medical providers.

    #Save42CFRPart2

    Reply

    • You are right. We providers must continue educating our colleagues, usually one at a time. Most conversations go well, some not so much. And advocacy groups like you’re involved with are so important too.

      Reply

    • Posted by Harper on June 17, 2019 at 7:30 pm

      As someone in treatment can you let me know how 42 cfr part 2 protects me in disclosing my treatment to a caregiver? It is very anxiety producing to decide to tell or not and I have been treated with judgemental and scorn when I told my primary caregiver, not even asking for any pain treatment, but due to concerns with chest pain. When I showed her a high ekg reading done at my clinic that I wanted to look into further due to chest pain symptoms I’d had long before I started treatment her response was it’s the methadone and I need to get off. I never had an irregular ekg before (or since thankfully) but hoped to look into it to make sure it wasn’t an issue. I never went back to her again and have since found a compassionate and educated physician as my primary caregiver that supports my treatment. I’m still concerned about disclosing my treatment to other physicians, especially if something were to happen where I could need pain relief.

      Reply

  2. Posted by Steve straubing on June 16, 2019 at 7:19 pm

    The confidentiality issue is a very thorny problem as it applies especially to methadone clinics. Here is the problem: Many of my pts who need surgery and report to their doc that they are on methadone are automatically stigmatized. Also many docs are clueless on how to manage post op pain in these pts. They assume, incorrectly, that their baseline dose of methadone is adequate for postop analgesia which of course is folly. And they also assume that their very real pain is just ‘drug seeking.On the other hand, if they don’t disclose that they’re on methadone, it won’t show up on a state PDMP and their doc may undertreat their acute pain. It’s a lose-lose situation for the patient in either case. Trying to find a surgeon who understands SUD’s and is non stigmatizing is a tall order and trying to get them to collaborate w me, (I always offer and give the patient my contact info for their surgeon) is also a very tall order.

    Reply

    • Thanks – insightful comment. I’d love to be able to tell me patients they can trust their doctors to do the right thing, but that’s not usually the case.

      Reply

  3. Reblogged this on My Sharing Blog.

    Reply

  4. Posted by Alan Wartenberg MD on June 17, 2019 at 2:27 pm

    You are on my healing prayer list, Jana

    Reply

  5. Posted by Harper on June 17, 2019 at 7:22 pm

    Best wishes for a speedy recovery. You are too valuable and rare in your field to your patients and wider community to let this put you down for long!

    Reply

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