What Otolaryngologists Should Consider When Prescribing Opioids

Clinical Scenario

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You are in your clinic office this morning, reviewing the patients you are scheduled to see today. You note that two of the patients will likely be challenging with respect to pain management, and you begin to consider what options you might have and how to approach the decision-making process with them. Both patients are known to you, and you believe you have a good patient–physician relationship with them.

Mrs. Smith is a 59-year-old housewife in whom you first diagnosed an invasive squamous cell carcinoma of the right lateral tongue six months ago. After a confirmatory biopsy, you performed a comprehensive evaluation of the patient, which did not reveal suspicious lymphadenopathy or metastatic disease. You offered the patient the options of surgery plus possible neck radiation versus primary chemoradiation, and, after due consideration, she chose the latter. Since completion of therapy three months ago, the patient has complained of intense pain (7/10 analog) in the oral cavity and upper neck, along with right shoulder pain. You have not identified any recurrence or residual tumor in the oral cavity or neck on imaging studies or physical examination. The patient did report a slight diminishment of the pain on the last examination two weeks ago but continues to request opioid prescriptions; however, you are at the point in time when you feel a re-evaluation of the opioid pain management you have prescribed is now in order.

The second patient of concern is a 37-year-old male paralegal who is now six weeks status post open reduction and internal fixation of a LeForte III fracture, including orbital floor fractures. Last month, you removed the maxillary-mandibular fixation, and there was no evidence of any complications from the injuries or surgical reconstruction on examination or repeat CT scan. The patient has been very forceful, however, that he has terrible facial pain and requires more refills of his opioid pain medications. You want to avoid a confrontation with the patient, and you consider the pain management options for his post-trauma pain.

How would you handle these cases?

Discussion

In the December 2017 issue of ENTtoday, the article “The Opioid Crisis: Five Truths Otolaryngologists Need to Know” discussed the threats of opioid overuse and misuse in the United States for patients, physicians, and society. The article identified five elements to consider when otolaryngologists prescribe opioids:

1. Your patients may already be on opioids;
2. The number of pills you prescribe matters;
3. You can probably decrease the amount of opioids you prescribe;
4. Patient education regarding proper use (and disposal) of opioids is necessary; and
5. Patients who want refills should be referred to pain management specialists.

These points can help guide the otolaryngologist in managing pain requirements by patients in the clinical setting. But the concerns of the opioid crisis and the responsible management of pain in patients require the otolaryngologist to make the best decisions for patients within the context of clinical and professional ethics.