RJM posted:
2019Lefty21 posted:
Pedaldad posted:

 

Personally, I never write for opioids for anything other than significant trauma and post-operative pain control.  Very rarely more than a few days, never more than 2 weeks even in the most dire injuries/surgeries.   Heaven forbid you show up on the operating table with a crushed limb.  But if you do, I promise you that you part of your medical management will include a scheduled regimen of opioids to assist in pain control.  I will promise you that you will appreciate it.    I also promise you that if written responsibly by the physician (almost always the case) and if you follow that regimen (less frequently the case), you will run little to no risk of addiction.  If you abuse/misuse it, that is where the problem is.

I have had major surgery including brain surgery as a result of a tbi from a fall, and have been able to avoid taking opioids as a personal choice and have gotten through the pain management issues, but how do you tell someone else to “suck it up buttercup” and avoid things they are prescribed? I have a son who is a freshman in college, and will now be receiving treatment from trainers and doctors away from me if necessary, and reading this thread scares the hell out of me. From a doctors standpoint, if you try to manage pain from surgery under a lesser painkiller will the pain eventually go away as the surgical wounds heal? Just trying to understand why anyone would ever want to risk the opioid addiction?!

I sucked it up post aortic dissection surgery after being sent home. I have a very high pain tolerance level. During my five week recovery at the hospital and rehab I was given Percocet for five weeks. But being in the hospital it was monitored. My cousin, a doctor took the Percocet away from me when I went home. He called the hospital and told them to prescribe something less dangerous. I went through withdrawal. It was a pleasant distraction from my recovery (sarcasm). 

The problem is patients back on their own, unmonitored with powerful, addictive medications. Relative to baseball you can’t just send a player home post TJ surgery with powerful, additive meds and expect everything to be ok. He wants to get back on the field as soon as possible before he loses his job. The player has to be monitored for signs of addiction. 

I can fully understand a person playing around with levels of medication and thinking they’re smart enough to handle it. I did it while dealing with negative side effects. But I wasn’t playing around with opioids. 

 

I can't explain the choice to keep someone on Percocet five weeks post surgery, especially not for aortic dissection surgery.  Without knowing the details,  this does not seem appropriate. 

As to why to take pain med post procedure: 

There is a real risk of developing a pain syndrome if you are under medicated during a serious injury or post surgery.  Complex regional pain syndromes (CRPS) are rare but very real in the extremities.  So let us assume pitcher x has a UCL repair (Tommy John) and has fear of opioids and chooses just to "deal with the pain".  There is increased chance that this individual develops CRPS. 

Imagine a grown athlete that comes in a few weeks post surgery crying in unbearable pain with his throwing arm wrapped in a pillow because even the breeze of a fan causes an intense sharp, stabbing pain that can't be stopped.  This is a rare but real entity post injury/surgery.  Talk to someone who has had it and you will come across people in extreme desperation.

Now you are facing being unable to work, sleep, drive, or even move because every small stimulus creates so much pain that it takes over your life.  You start to self medicate with alcohol or whatever you can get your hands on.   Your hope changes from full recovery and return to the field to maybe someday just being able to get back to normal daily activities.  Individuals have even committed suicide because of the despair. 

Generally, I advise my patient to take their prescribed pain med for the day of surgery/injury, the day after surgery/injury, and beginning day 3 to take it only if needed.  Most individuals will turn a corner about 3-5 days after surgery, once the inflammatory phase of healing has been passed.  That does not mean they are pain free, but have enough reduction in acute pain that they don't need medicine.  The need to take opioids beyond this point starts to raise flags for me. 

There are medicines that can assist in pain control, but in my world we generally avoid NSAIDS (ibuprofen, naproxen, etc) if bone is involved because it adversely affects healing times.   Other meds also have potential for abuse and intravenous tylenol is sometimes employed to reduce the quantity of opioids required for pain control in extreme situations.

Pedaldad posted:

IWe all agree that there is an opioid epidemic.  We all agree that there are a certain amount of physicians that have played a role.  But let me shed some light on my background vs others that have chosen to write some very inflammatory, inaccurate, and unproductive remarks on this topic.

I agree there were some inflammatory remarks. As we clearly learned there was poor control of it's prescribed use and were intentionally misled on it's potency and addictive effects. I think the Purdue current lawsuits and previous settled and criminal prosecutions prove that.   

I am surgeon in my early 50s, and know full well what medicine was in the 90's as well as today.  For the past decade I have been part of the ortho faculty in a level 1 trauma center at one of are nation's largest academic institutions.  This means my partners and I take care of the patients no one else wants - the train-wreck traumas(literally and figuratively), the homeless, the uninsured, the chemically dependent - they all get dumped on our front door with injuries that make most look the other way.  So I am an authority on this thread topic.

I am very grateful for physicians like you and your partners. I do appreciate your opinion and responses, I may not agree with them but for the record I disagree with many authorities from Nobel Laureates to law enforcement officials (the radar was not properly calibrated).

I know what constitutes a peer reviewed scientific article, and the citation referenced above simply doesn't come close, but it is not void of poignant information.  The referenced citation is actually a newsletter  from the National Institute of Drug Abuse.  The excerpt chosen is misleading, it leaves out the sections that states 21 - 29% of people prescribed opioids misuse them (patient not complying with how they were prescribed, i.e. personal responsibility) and this directly leads to an opioid disorder in 8-12%.   Additionally 4-6% of those that misuse the opioid medications will develop heroin addiction.

Newsletter from the NIH that referenced peer review journals, again we will just have to agree to disagree on the scientific value of those journals. Yes, there is patient misuse that contribute to this problem, but again IMO this is an expected result from a poorly designed system of dispensing a highly addictive but necessary medication. 

The internet is a great thing, but medical sources are being cited that people really don't understand. Additionally, using inflammatory hyperbole -"giving out prescriptions likeHalloween Candy" or "lead to addiction in a matter of days" is grossly inaccurate and irresponsible as to the source of the problem.  It clearly is abuser driven as this newsletter suggests.

I read the references via pubmed and even read the articles' references. I won't lay out my CV here but I did understand. Yes there was hyperbole, but this is a very personal topic and we are on a public message board and this is quite tame relative to political debates on a baseball thread.  

My pain management colleagues can treat patients that require opioid pain medicines for years without them ever developing physical dependence or psychological addiction with proper counseling and patient compliance to the dosing regimen.

Yes, the majority learned to do it right and they should be applauded. However, the fact is we are in crisis and it was over prescribed. 

Referring to the AMA as a credible source of medical information shows a complete lack of understanding as to what the AMA is.  It is not a medical organization.  It is a political organization with a political agenda, not a defender of medical integrity.  In fact, it only has about 10-12% membership of the practicing U.S. medical docs.  Most members are hold overs from the ]70s, or have a political agenda that coincides with the AMA.  Membership cost is nominal (less than $500 per year) but most of us choose not to participate because we don't agree with a political organization that pretends to be a proponent of healthcare.

I don't disagree about AMA's  political agenda. However they and the ACS opiod task force also support changes to prescription practices.

Personally, I never write for opioids for anything other than significant trauma and post-operative pain control.  Very rarely more than a few days, never more than 2 weeks even in the most dire injuries/surgeries.   Heaven forbid you show up on the operating table with a crushed limb.  But if you do, I promise you that you part of your medical management will include a scheduled regimen of opioids to assist in pain control.  I will promise you that you will appreciate it.   

Again, I thank you for your dedicated and tireless service to others. I have had post-surgical prescribed short dose opiods and I was grateful for them.   

I also promise you that if written responsibly by the physician (almost always the case) and if you follow that regimen (less frequently the case), you will run little to no risk of addiction.  If you abuse/misuse it, that is where the problem is.

The road to misuse/abuse is complex, considering the highly addictive nature of this controlled substance. How it gets misused and abused is relevant. Clearly if the pad was not part of the problems, we would not have PMDPs 

 

2022NYC, it appears you have an issue with doctors in general it seems. As a guy who has had ACL reconstruction, appendectomy, L5 discectomy, I can tell you I appreciate what pedaldad is sharing with this board and it should be taken to heart. Post ACL reconstruction, the pain subsided in 3-5 days (unless my kid or dog jumped on my leg) and OTC pain relievers did the job. Worst pain ever that they weren’t even a consideration - kidney stones - and don’t get me started. WORST PAIN EVER (ladies, I have never given birth so have no frame of reference...but trust me...I cried). 

Thanks Pedaldad, appreciate your knowledge you have shared.

I am not an authority on this topic but still want to join the conversation.  

My dad was a dedicated chiropractor, considered a leader in his field by the institution.  He never stopped schooling, researching, learning, growing within his profession.  He wrote books, was constantly asked to speak at seminars, teach at schools and clinics, etc.  He explored every aspect of related holistic healing - all the various adjustment techniques, acupuncture, healing stones (yeah, that was an interesting period in a conservative midwest household in the 70's), you name it.  And, this was WAY before any of this became the least bit common here in the states.  It was not uncommon for people to share with me, unsolicited, how my dad saved their lives, saved them from desperate physical ailments.  He was, by all accounts, a great doctor (probably much like pedaldad).

However, he was also fully immersed in his profession and that meant (at the time) fully buying into the belief that traditional American medicine had little value, how the prescription of medication was almost never appropriate.  All six of us kids rarely if ever saw the inside of a hospital or medical clinic growing up.  Dad handled everything.  Problem is, as was customary of the time and place, Dad smoked and drank regularly.  Much later in life (after retirement), when those things started causing real physical ailments, at some point, traditional medicine was the only avenue.  I believe, only then, did he come to believe that the true approach to proper medical care is a combination of holistic and traditional medicine.  Things have improved over the last fifty years, but there is still a huge chasm between the primary foundations of traditional medicine and holistic medicine. 

I have been involved in other professions and endeavors where I was fully immersed and very well informed in my position and believed 1000% that my actions were the right course.  Later, only after stepping completely away, I sometimes was able to see a bigger picture and came to realize that wasn't the case, even with the best of intentions and tons of experience and knowledge to fall back on.

I believe that even the very best doctors on both sides still tend to rely heavily on their college training and industry status quo as "the truth".  I think there is a bigger picture that has yet to be clearly seen by most that would involve a much more proper blend of prevention, lifestyle, traditional and holistic medicine.  I know we have taken a few baby steps in that direction but we have so far to go.

Another point... I'm guessing that Tyler Skaggs' tragedy was, as has been discussed, tied to some earlier event of prescription due to his TJ and spiraled into addiction.  I agree with those who classify this as disease.  However, it is my perception that the national epidemic involves a much larger contingency of drug abusers that are just looking for the high, who's path with opioids never included actual prescription by a real doctor for a real medical condition.  That is us as a society becoming weaker.  Isn't that the real issue on a national level?  So there is validity to both positions... addiction is a disease and we are responsible for our actions.

   

cabbagedad posted:

I am not an authority on this topic but still want to join the conversation.  

My dad was a dedicated chiropractor, considered a leader in his field by the institution.  He never stopped schooling, researching, learning, growing within his profession.  He wrote books, was constantly asked to speak at seminars, teach at schools and clinics, etc.  He explored every aspect of related holistic healing - all the various adjustment techniques, acupuncture, healing stones (yeah, that was an interesting period in a conservative midwest household in the 70's), you name it.  And, this was WAY before any of this became the least bit common here in the states.  It was not uncommon for people to share with me, unsolicited, how my dad saved their lives, saved them from desperate physical ailments.  He was, by all accounts, a great doctor (probably much like pedaldad).

However, he was also fully immersed in his profession and that meant (at the time) fully buying into the belief that traditional American medicine had little value, how the prescription of medication was almost never appropriate.  All six of us kids rarely if ever saw the inside of a hospital or medical clinic growing up.  Dad handled everything.  Problem is, as was customary of the time and place, Dad smoked and drank regularly.  Much later in life (after retirement), when those things started causing real physical ailments, at some point, traditional medicine was the only avenue.  I believe, only then, did he come to believe that the true approach to proper medical care is a combination of holistic and traditional medicine.  Things have improved over the last fifty years, but there is still a huge chasm between the primary foundations of traditional medicine and holistic medicine. 

I have been involved in other professions and endeavors where I was fully immersed and very well informed in my position and believed 1000% that my actions were the right course.  Later, only after stepping completely away, I sometimes was able to see a bigger picture and came to realize that wasn't the case, even with the best of intentions and tons of experience and knowledge to fall back on.

I believe that even the very best doctors on both sides still tend to rely heavily on their college training and industry status quo as "the truth".  I think there is a bigger picture that has yet to be clearly seen by most that would involve a much more proper blend of prevention, lifestyle, traditional and holistic medicine.  I know we have taken a few baby steps in that direction but we have so far to go.

Another point... I'm guessing that Tyler Skaggs' tragedy was, as has been discussed, tied to some earlier event of prescription due to his TJ and spiraled into addiction.  I agree with those who classify this as disease.  However, it is my perception that the national epidemic involves a much larger contingency of drug abusers that are just looking for the high, who's path with opioids never included actual prescription by a real doctor for a real medical condition.  That is us as a society becoming weaker.  Isn't that the real issue on a national level?  So there is validity to both positions... addiction is a disease and we are responsible for our actions.

   

Thank you for your very diplomatic post. 

collegebaseballrecruitingguide posted:

2022NYC, it appears you have an issue with doctors in general it seems. As a guy who has had ACL reconstruction, appendectomy, L5 discectomy, I can tell you I appreciate what pedaldad is sharing with this board and it should be taken to heart. Post ACL reconstruction, the pain subsided in 3-5 days (unless my kid or dog jumped on my leg) and OTC pain relievers did the job. Worst pain ever that they weren’t even a consideration - kidney stones - and don’t get me started. WORST PAIN EVER (ladies, I have never given birth so have no frame of reference...but trust me...I cried). 

Thanks Pedaldad, appreciate your knowledge you have shared.

I appreciate and am very grateful to the wonderful physicians in my life. I am being critical about prescription practices that  did have a part in the opiod crisis and provided references as well as listed practice changes from their politburo as well as a bonafide professional soceity. If  you construe that as having an issue with doctors...that is your right but I would disagree. 

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