Posts Tagged ‘appropriate use of opioids’

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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In Praise of Opioids

Tibia xray

Some readers of my blog mistakenly think I’m opposed to all opioids, all of the time. That’s not true at all. I’m only opposed to the misuse or addiction to opioids, which can cause undue suffering. I’m a big fan of opioids, when used cautiously and in the right setting.

The benefit of opioids was driven home to me personally when I fell and broke my leg several years ago. Here’s the post from several years ago, describing my experience. Far from opposing opioids, I was thankful for them.

While walking my dog, I fell and broke my tibia and fibula (both bones of the lower leg). The break was obvious; I had to hold my foot to keep it from moving to an odd and painful angle. I sat on the ground, thinking, “Oh shit. This is going to hurt, and I’m going to have to go to the hospital emergency room on a Friday night to get a cast.”

And of course it did hurt. It was the worst pain I’ve ever had. I couldn’t get into a car to go to the hospital, since both hands were busy holding my foot. If I let go, my foot drooped to a sad angle. I wasn’t going anywhere without additional help. So my fiancé called 911.

First to arrive was a huge fire truck, with ladders, hoses, etc. One of three or four firemen took my blood pressure, asked me a few questions, and said EMS would be there soon. When EMS arrived, three or so more young men sprang from their vehicle. They asked the same questions all over again. At one point there were five or six burly young men who all responded to the 911 call, standing around me in a semi-circle. It felt like a bit of overkill, but I didn’t mind.

The worst part of my whole ordeal was when EMS workers tried to splint my leg with a device obviously meant for a much taller person. Putting the splint on caused my foot to move to an angle that God did not intend. The grinding of my bones made me sick to my stomach, to the dismay of EMS personnel. I’m told I gave my neighbors quite a show.

Once I finally got inside the ambulance, the EMS worker easily slid an IV into my arm and gave me a dose of fentanyl.

I have never taken any IV opioids, to my knowledge. Immediately, I felt hot all over, and then started weeping with relief. I wouldn’t say I felt euphoria, so much as a profound relief that the pain no longer hurt. That also sounds odd; I still had pain… but it didn’t bother me, and I felt like everything was going to be OK. In that moment, I had a better idea what my opioid-addicted patients describe when they tell me of the allure of opioids. Under the influence, I felt like nothing would bother me, physically or emotionally.

Then my eyes felt like they were spinning around in my head like pinballs, but I didn’t care about that, either. Then I got very chatty and talked nonstop to the hospital. I remember I told the EMS worker about how traffic lights looked like candy – lime, lemon, and cherry – so I may have been a little out of it.

The emergency room doctor ordered X-rays that showed the tib/fib fracture. I thought I would get a cast, and then go home. Wrong. The nurse told me I was being admitted for surgery on my broken leg. I wasn’t happy about this, especially since I hadn’t even talked to the orthopedic surgeon who would operate. I had questions. Why couldn’t I go home with a cast? What was he going to do at surgery, and why was it better than a cast?

So I stayed in the hospital that night, edgy about what surgery was proposed and full of questions. My leg hurt, but the emergency room staff had placed a plaster-type splint, or partial cast, on my leg, which kept the bones from moving around. As long as I kept it still and elevated, the pain wasn’t too bad. I had several shots of morphine through the night. I didn’t feel high from the morphine, but the shots put me to sleep, a good thing.

The surgeon came into my hospital room mid-morning, and talked to me about the advantages of having an intramedullary rod place through the center of my tibia to hold the broken sections together. This sounded extreme, but the surgeon said in “someone your age,” with simple casting the bones would take longer to heal. At my age, there was a relatively high rate of non-union, which would result in surgery at a later date anyway.

It took me longer to process the information than it should; I was stuck on that “someone your age” comment. I’m a young-looking 52, and finally realized I had to be much older than this young surgeon, who could have passed for twenty-five… Maaaaaybe the comment fit.

Anyway, I agreed to the surgery. Pre-op, the anesthesiologist gave me fentanyl, and again I had the feeling my eyeballs were spinning in circles and I got chatty. Then he must have given me something else that put me out completely, because the next thing I remember I was waking up back in my hospital room. I was upset when I didn’t see a cast, because I thought that meant I didn’t have the surgery. I didn’t know that an intramedullary rod takes the place of a cast…kind of like having a cast on the inside.

Since that surgery, I haven’t had much pain. I took my last morphine injection the night after surgery.
I’m no martyr. If I have pain, I want pain medication. The surgeon, knowing what I do for a living, asked me if I wanted to go home with any opioids. I said yes. I told him please prescribe what you would for anyone else. He prescribed twenty-five Percocet. I took two the morning after I got home, and they relieved the pain, but left me a little groggy and sleepy. I’d had enough of that in the hospital, and was eager to do some reading and writing, so that was the last dose of opioids for my broken leg. After making it a week with no opioids, I flushed the remaining twenty-three pills.

I had one bad spell after falling on my crutches, twisting the broken leg a little. The rod held my tibia in place, but the fibula hurt intensely for about twenty minutes before I was able to calm the pain with elevation, ice, and ibuprofen.

I think I’ve done well during my recovery from the broken leg. This surgery allowed me to heal much faster. It’s now almost six weeks since my surgery, and the above x-ray was taken today. My leg hurts only when I walk around. Ibuprofen and Tylenol have worked fine. I’ve been careful, especially during the first few weeks, to keep my leg elevated and use ice for swelling. I’m convinced elevation and ice helped a great deal.

This week I can walk with the help of a cane. It does hurt to walk, but it’s the kind of hurt that’s necessary to build back my muscles. If the pain gets too bad, I sit down and elevate my leg again.

I know I’m very lucky. The fracture happened in a place where help was readily available. It was less than thirty minutes from the time I broke my leg until I got a shot of a powerful opioid, fentanyl. This medication was a godsend to me.

I have health insurance, and could afford to get the surgery to help my leg heal quickly. My surgeon did a wonderful job, even if I do have underwear older than he is. I was able to take several weeks off work to keep my leg elevated for better healing and less pain. I have a loving fiancé who didn’t mind being my legs for a few weeks. Some people don’t have any of those things, so I’m very grateful.

What is the point of this blog, other than to blather on about my surgery and broken leg? It’s this: opioids are great when used the in the right situation. For acute pain, they are truly a blessing to mankind. But these drugs produce pleasure, and anyone can get addicted to that intensely good feeling.
Doctors have to find a balance between empathy and caution. Let’s not be stingy with opioids during acute medical situations with intense pain. Even in a patient with known addiction, opioids shouldn’t be withheld for an acutely painful medical situation, because that would be unethical.

But we can’t ignore the dangers of addiction, particularly if opioids are used for more than a few weeks. Even if we feel uncomfortable talking about addiction, we have to have those conversations with our patients. And please, fellow doctors, see patients with addictions as people with a treatable disease, who deserve the same respect as patients with any other disease. You don’t need to kick them out of your practice; you do need to refer them for help.