Quintessential student-athlete attempts suicide with unused hydrocodone

I awoke to a text message at 11 p.m. on a Monday night from one of the trainers. I thought it was about an athlete with a hand or elbow injury needing urgent surgical intervention. But, half asleep, I read: “Please call regarding patient that was assaulted over the weekend and attempted suicide today by taking a large amount of hydrocodone. She is in the intensive care unit (ICU).”

I sat up, completely awake. After a quick phone conversation, there was no need to look up the patient. I knew who it was immediately. The patient was the quintessential student-athlete—focused on school and sports, easy to coach through the postoperative period, and an overall class act. I repaired the ulnar collateral ligament of her thumb metacarpophalangeal joint on a Friday, and by Monday, she was back at school. I remembered her not using any opioids, as she didn’t want it to interfere with school. She coasted through recovery and was released back to play.

I couldn’t remember how many pills I had prescribed, so I checked: 60 tablets of hydrocodone. My heart dropped. My prescription had harmed this woman. The pills sat for more than three months in a medicine cabinet in a college dorm room, available to anyone instead of being safely disposed. An estimated 67 percent of postoperative medications go unused after surgery, but in this case, it was 100 percent.

No national or international guidelines, strategies, or standards exist for opioid prescribing. We receive no specific education during medical training to help prepare us for safe and effective alleviation of pain. A study found that 70 percent of opioid misuse begins with access to another person’s opioid prescription. Many of the pills we prescribe are diverted to nonmedical uses. Those unused pills, if not used by my patient, might have been part of a tragic story involving a different college student.

For me, an overdose or a new misuse disorder is iatrogenic harm—a medical error. The culture of overprescribing, whether it’s because we think it will improve patient satisfaction, avoid inconvenient phone calls, or enable patients to save pills for a rainy day or for exercises, must end. Studies have shown that fewer tablets in postoperative prescriptions decrease the rate of misuse.

The unused hydrocodone should not have sat idle in the patient’s medicine cabinet. I didn’t ask her to bring it in for disposal. Our hospital didn’t start the bring-back program until months later. There are other places to dispose medications, which can easily be found on the Drug Enforcement Administration’s website. I simply did not provide her with the knowledge of how to protect herself, because I was not properly educated either.

Now there are fliers in every clinic room letting patients know about proper disposal of medications. Only 25 percent of all patients know that disposal programs exist. When they do know, they are more likely to lock up their medications, avoid sharing with family members, and safely dispose of extra pills. Patients are just as scared as surgeons about the risks involved with opioids.

Studies have shown that opioids are prescribed long after the body heals. It’s hard to know whether the amount we send our patients home with is appropriate to manage the nociception created by surgery; whether it is being used as self-medication for stress and distress; whether it is being sold for rent money; or whether it is given to, or stolen by, another person.

A number of tools are available to help patients and surgeons with safe and effective pain management. Each state has a prescription drug monitoring website available to all doctors, and the information can be shared among states. Several electronic health records now allow direct linking to prescription monitoring websites. It’s worth it to routinely look up the patients for whom we prescribe opioids. Physicians can use the Opioid Risk Tool from AAOS to quantify risk, measure symptoms of depression, and identify ineffective coping strategies. The AAOS orthopinion article “How ‘Mother Nature’ Helps Us Heal” is a good patient handout for office use.

I create a pain management plan with all my patients and have them sign it. This effort can be time consuming and a bit awkward, but I have made it standard practice. The document describes how to alleviate pain without opioids, notes that opioids are for short-term relief, and explains how to dispose of unused pills.

After a week in the ICU, the patient left without any permanent physical damage to her body. She quit her sport, dropped out of school, and moved home. My job was to “do no harm,” and I am not sure I followed that oath. If the opioids had not been sitting in her medicine cabinet, she may have had the night to think things through. I am now a strong advocate for safe and effective alleviation of pain and optimal opioid stewardship. I hope this story will encourage you to join me.

References

1. McCabe SE, West BT, Teter CJ, et al: Medical and nonmedical use of prescription opioids among high school seniors in the United States. Arch Pediatr Adolesc Med 2012;166:797-802.
2. Han B, Compton WM, Blanco C, et al: Prescription opioid use, misuse, and use disorders in U.S. adults: 2015 National Survey on Drug Use and Health. Ann Intern Med 2017;167:293-301.
3. Bates C, Laciak R, Southwick A, et al: Over prescription of postoperative narcotics: a look at postoperative pain medication delivery, consumption and disposal in urological practice. J Urol 2011;185:551-5.
4. Brat GA, Agniel D, Beam A, et al: Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018;360:j5790.
5. Egan KL, Gregory E, Sparks M, et al: From dispensed to disposed: evaluating the effectiveness of disposal programs through a comparison with prescription drug monitoring program data. AM J Drug Alcohol Abuse 2017;43:69-77.

Megan Conti Mica, MD, is an assistant professor who specializes in hand and upper extremity surgery at the University of Chicago.