Post provided by Barbara Bergin, MD
Here’s the story of two fictitious young men. They are not actually my patients, but I see these two scenarios played out over and over in my practice. These are two teens, both of whom tore their anterior cruciate ligaments.
Hank asks for no pain pills following his injury, even though they were offered. He thinks he’ll do fine on Tylenol. Following the MRI, which confirmed the presence of an ACL tear, he wants to make plans for surgery as soon as possible. He’s in high school and knows he’ll probably have to miss a couple of days. He asks if it’s possible to get a handicap parking permit. That way he’ll be able to park a little closer to his school. He asks if the doctor can estimate when he’ll be able to go back to school so he can make arrangements with his teachers. He has his surgery and is encouraged to go ahead and take his pain pills as needed, but after a couple of days he discontinues them and takes Tylenol instead. He doesn’t like the way the pills make him feel and he can’t study while he’s on them. He goes back to classes even before his sutures are out. He quickly regains his muscle strength and range of motion and within a few weeks has stopped using crutches.
After his injury Alex got a bottle of narcotic pain pills from the emergency room. He’s been taking them every 4-6 hours, just like the directions on the bottle. They don’t really work that well anyway. Following the MRI, which confirmed the presence of an ACL tear, he wants to make plans to have surgery. He’s a freshman in college and so he’s going to let his parents know that he’s going to have to take off the rest of the semester and needs a note to take to the registrar’s office. His knee is killing him even before surgery so he figures it’s going to be even worse afterward. He has very little swelling but is having difficulty moving his knee. At the end of the visit he reminds the doctor that he will probably need another prescription for pain pills. He’s not out yet but he doesn’t want to get caught over the weekend without them and so he may as well stock up ahead of time. And he reminds the doctor that the Vicodin is not even touching the pain, so could the doctor make sure he gives him something stronger.
After surgery, he struggles with his rehabilitation. He takes the stronger pain pills every 4-6 hours, like it says on the bottle. He takes them before he goes to physical therapy so that he can tolerate it. He takes two before bed at night, just to be able to sleep. Sometimes he takes another one if he wakes up in the middle of the night. Six weeks after the surgery he is still requesting pain pills weekly and the doctor has to start a program of weaning him off the pills. The doctor gets a call from the pharmacy saying that Alex is also getting pain pills from his primary care physician.
Hank and Alex represent the whole spectrum of responses to pain. Alex isn’t a bad person. He’s not taking illegal drugs. He’s not selling drugs. Hank and Alex just respond differently to pain. But sometimes patients like Alex get into serious trouble taking prescription narcotics without even recognizing that there is a potential problem. Physicians don’t want to see patients suffer. So they’re reluctant to deny the pain pills when the patient is complaining. This can inadvertently lead to a pattern of prescribing narcotics that eventually contributes to addiction. Then drug seeking behaviors develop, which can last a lifetime.
The most important things to remember are:
1) Use narcotic pain pills only when absolutely necessary.
Hank asks for no pain pills following his injury, even though they were offered. He thinks he’ll do fine on Tylenol. Following the MRI, which confirmed the presence of an ACL tear, he wants to make plans for surgery as soon as possible. He’s in high school and knows he’ll probably have to miss a couple of days. He asks if it’s possible to get a handicap parking permit. That way he’ll be able to park a little closer to his school. He asks if the doctor can estimate when he’ll be able to go back to school so he can make arrangements with his teachers. He has his surgery and is encouraged to go ahead and take his pain pills as needed, but after a couple of days he discontinues them and takes Tylenol instead. He doesn’t like the way the pills make him feel and he can’t study while he’s on them. He goes back to classes even before his sutures are out. He quickly regains his muscle strength and range of motion and within a few weeks has stopped using crutches.
After his injury Alex got a bottle of narcotic pain pills from the emergency room. He’s been taking them every 4-6 hours, just like the directions on the bottle. They don’t really work that well anyway. Following the MRI, which confirmed the presence of an ACL tear, he wants to make plans to have surgery. He’s a freshman in college and so he’s going to let his parents know that he’s going to have to take off the rest of the semester and needs a note to take to the registrar’s office. His knee is killing him even before surgery so he figures it’s going to be even worse afterward. He has very little swelling but is having difficulty moving his knee. At the end of the visit he reminds the doctor that he will probably need another prescription for pain pills. He’s not out yet but he doesn’t want to get caught over the weekend without them and so he may as well stock up ahead of time. And he reminds the doctor that the Vicodin is not even touching the pain, so could the doctor make sure he gives him something stronger.
After surgery, he struggles with his rehabilitation. He takes the stronger pain pills every 4-6 hours, like it says on the bottle. He takes them before he goes to physical therapy so that he can tolerate it. He takes two before bed at night, just to be able to sleep. Sometimes he takes another one if he wakes up in the middle of the night. Six weeks after the surgery he is still requesting pain pills weekly and the doctor has to start a program of weaning him off the pills. The doctor gets a call from the pharmacy saying that Alex is also getting pain pills from his primary care physician.
Hank and Alex represent the whole spectrum of responses to pain. Alex isn’t a bad person. He’s not taking illegal drugs. He’s not selling drugs. Hank and Alex just respond differently to pain. But sometimes patients like Alex get into serious trouble taking prescription narcotics without even recognizing that there is a potential problem. Physicians don’t want to see patients suffer. So they’re reluctant to deny the pain pills when the patient is complaining. This can inadvertently lead to a pattern of prescribing narcotics that eventually contributes to addiction. Then drug seeking behaviors develop, which can last a lifetime.
The most important things to remember are:
1) Use narcotic pain pills only when absolutely necessary.
2) Use them sparingly and not necessarily “as directed” on the bottle. It’s not like taking an anti-biotic, which must be taken at regular intervals around the clock in order be effective. Take them less if possible. The prescription dose of a medication that is prescribed “as needed” means that you can take them less if a smaller dose works sufficiently.
3) Have a healthy respect for prescription narcotics. They are not benign medications.
4) Once you’ve transitioned from the narcotic to over-the-counter medications, such as Tylenol or Advil, then get rid of them by following the FDA recommendations on this website: http://www.fda.gov/forconsumers/consumerupdates/ucm101653.htm
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