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AANS Neurosurgeon | Volume 26, Number 1, 2017

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Point/Counterpoint: Opioid Prescriptions — What is a Neurosurgeon's Responsibility?

The Point position is taken by Sharona Ben-Haim, MD. The Counterpoint position is taken by Christopher J. Winfree, MD, FAANS.

Point: Neurosurgeons take care of patients in both acute and chronic pain and should have the capacity to treat these patients within the scope of their practice. Since opioids represent a good therapeutic option for the treatment of many types of pain, neurosurgeons should utilize these medications when necessary.

Counterpoint: Neurosurgeons should be prepared to treat routine postoperative pain typically encountered in neurosurgical practice, which can include the use of short term opioid medications. However, the treatment of patients with chronic pain, or patients who require long-term opioids after surgery, is a complex endeavor that is outside the scope of routine neurosurgical practice. Neurosurgeons should not be the primary provider of pain medications for these patients.

Point: The treatment of complex pain is indeed within the scope of neurosurgical practice. Neurosurgeons have treated pain since the inception of the field and have pioneered advancements for the most complex types of pain syndromes. All neurosurgeons are trained in the diagnosis and treatment of a variety of acute and chronic pain disorders. This is part of residency, board certification, maintenance of certification (MOC) and continuing medical education (CME).

In many subspecialties, including complex spine surgery, neurosurgical procedures have become progressively more complicated and extensive, and the resultant postoperative pain demands have similarly been raised. Additionally, improvements in critical care have allowed patients to survive more complex and potentially painful injuries to multiple organ systems. These patients need adequate pain treatment by their treating physicians. 

Counterpoint: While neurosurgeons should certainly be allowed and expected to treat complicated patients with pre-existing or postoperative chronic pain, they should not be obligated to treat these patients’ complex pain needs. These patients are best treated by a specialist in the medical management of chronic pain, such as a pain management physician. Most neurosurgeons cannot properly commit to the comprehensive management of these patients, which includes aspects outside the scope of a typical neurosurgical practice that may involve employing tools like the use of opioid contracts, keeping up with new and rapidly changing legislation on prescribing requirements and providing these patients with psychological support.

Point: Any neurosurgeon who becomes a specialist in treating such challenging patients must be capable of handling their postoperative pain requirements in a competent and humane fashion. 

Counterpoint: Many of the needs of these complex patients have already become compartmentalized within different subspecialties in order to provide the best level of care. For the complex neurosurgical patient, there are often a variety of specialists involved, including critical care, infectious disease and trauma specialists, amongst others. The management of pain in these patients is no different that the management of any other organ system and should be handled by the most appropriate specialist available, which is generally a pain management physician.

Point: Neurosurgeons can, and should, handle all of the postoperative pain management in these patients. They are uniquely capable of effectively incorporating the treatment of pain into the overall clinical picture.

Counterpoint: While neurosurgeons are certainly capable of becoming specialists of chronic pain management themselves, the management of a chronic pain patient who has been on chronic opioids for many years can be difficult, time consuming and fraught with complications. Recently, physicians have been charged and convicted of felonies, including manslaughter and murder, for overprescribing opioids. Neurosurgeons who accept this responsibility need to familiarize themselves with an entirely different and rapidly evolving field to be sufficiently competent.

Overall, the complex neurosurgical pain patient will be best served by the most capable physician with expertise, and ideally fellowship training, in the field of pain management. If this happens to be the treating neurosurgeon, based upon their interest, training and practice, then they should be allowed to manage these issues. Otherwise, neurosurgeons should be encouraged to involve a pain specialist, when appropriate, to help manage the needs of these complex patients.

Point: To summarize, neurosurgeons should write opioid prescriptions and medically manage neurosurgical pain; however, this should be done by the neurosurgeon only to the extent that they are comfortable doing so with their training and experience. This is usually for routine postoperative pain management for patients undergoing straightforward cranial, spine and nerve surgery. Once the situation becomes more complex, for example in the setting of the polytrauma patient with amplified pain issues, the postoperative chronic pain patient on long-term opioids or the chronic patient needing long-term opioid maintenance therapy under the guidance of an opioid contract, then the neurosurgeon should have the option of involving a pain management specialist to assume some of these responsibilities.

 

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