Is Plastic Surgery Contributing to the U.S. Opioid Crisis?

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According to a special topic paper in this month's issue of Plastic and Reconstructive Surgery, the official medical journal of the American Society of Plastic Surgeons (ASPS), the opioid medications being prescribed for pain management after plastic surgery procedures may be contributing to the ongoing opioid epidemic in the United States.

In the article, written by doctors from the University of British Columbia, Vancouver, and the University of Toronto, the spotlight is put on the current opioid crisis and its magnitude in our country. "The scale of the opioid addiction epidemic is difficult to exaggerate," says author Daniel Demsey, MD. "The United States of America contains 4.6 percent of the world’s total population, but consumes two-thirds of the world's opioid supply. Prescription opioid use disorder is defined as the chronic use of prescription opioid medication in a way other than prescribed, or when not prescribed, and may overlap with a use disorder of illicit opioids (such as heroin), as well as other substances. In 2015, prescription opioid overdose was the cause of 28,647 deaths in the United States."

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Dr. Demsey, a plastic surgery resident at University of British Columbia, says he became interested in the topic of addiction after seeing it affect some people very close to him. "This proved to be a shock in terms of how ignorant I had been of the problem, and how little it was understood by my colleagues. As I reviewed more of the literature on substance addictions, it became more apparent to me that there was a role being played by surgeons as prescribers of potentially addictive medications to help with postoperative pain. With that interest, I put together a team of authors for the paper that included physicians from different specialties relating to the problem—a senior plastic surgeon, and addiction medicine specialist and an anesthetist who focuses on chronic pain and long-term opioid use after surgery."

The paper details the different roles opioids play in plastic surgery: Patients are exposed to potentially addictive medications to cut down on post-surgical pain, as well as contributing to the street supply of opioid drugs by passing off unused pills to other people. "Patients with previous chronic opioid use are more likely to still be taking these drugs one year after surgery," explains Dr. Demsey. 

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After speaking to multiple plastic surgeons about the topic of this paper, as well as Dr. Demsey himself, it's clear that the aesthetic community isn't currently benefiting from proper education on the use of opioids and effective alternatives. "It is extremely important for physicians to be informed about the issue, and awareness is increasing across multiple specialties," says Dr. Demsey. "From the top, the U.S. surgeon general published an extensive report called Facing Addiction in America last year, which identified addiction as one of the major health issues facing the United States. At a more local level, there was a lecture on the topic at the Canadian Society of Plastic Surgeons meeting this past spring. So, awareness is growing to the scale and scope of the opioid addiction crisis across medical specialties. What is less clear is what exactly we should do about it—there is precious little good research on addiction treatment."

New York facial plastic surgeon Jennifer Levine, MD, agrees and says New York state has sent out several advisories about the crisis, but there has been no specific guidelines or training on this topic. "I think pain management is critical to the well-being of a patient," explains Dr. Levine. "I make sure to screen patients for possible opioid abuse by checking their current medications and asking if they have taken any form of opioids in the past. I try to manage my own patients’ pain starting in the operating room where I usually use a combination of shorter and longer-acting local anesthetics so the patient does not wake up in pain. Facial plastic surgery in general is associated with less pain than body or abdominal procedures. I also believe in using the least potent opioid to control pain. One other important thing to consider on this topic is e-prescribing. With patients able to get prescription drugs over the internet, doctors are also supposed to cross-reference the database to ensure patients are not receiving opioids from multiple providers."

Irvine, CA, plastic surgeon Andrew Smith, MD, also recognizes the opioid epidemic in the U.S. and thinks the article brings up several significant points. "This is an important consideration, as many of our patients require narcotic pain meds after elective or reconstructive plastic surgeries. It is incumbent that we are aware of this problem and judiciously prescribe opioids for our patients. I agree that combination treatments using non-narcotics to treat pain are an important strategy to consider. One example I have found beneficial is the use of a long-acting local anesthetic (Exparel) for abdominoplasty patients, which has greatly reduced the use of narcotic pain meds in my practice. I think we need to be aware of this problem in our society and be thoughtful in our approach to treating our patients' postoperative pain." 

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In addition to the education and training needed for surgeons, it's also critical that patients are aware of this crisis as well. If you are planning to undergo plastic or reconstructive surgery and your doctor has made you aware of the potential need for narcotic pain meds, don't be afraid to ask questions to confirm you understand how to avoid misuse and abuse of these powerful drugs. Therefore, you can be sure you won't become another statistic in a paper like this one. 

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