Post-op Pain Relief for Mr. Merrick Garland?

Mr. Merrick Garland had back surgery over the weekend. Specifically, he had an interlaminar decompression to address his lumbar spinal stenosis. It’s a common, minimally invasive surgery. But, surgery is surgery. There’s always risk. So we pray for a speedy recovery and we wish him nothing but the best long term.

However, we can’t help but conjecture about his post-operative pain management. He’s the nation’s top federal law enforcement agent, after all. He oversees the Department of Justice (DOJ) and, by extension, all subsidiary law enforcement agencies, including the Drug Enforcement Agency (DEA). Over the weekend, he added another title – surgical patient – and as part of that role, he likely received opioids during and after the surgery for his pain management. That’s the standard of care for a laminar decompression.

It poses an interesting conundrum. Does Mr. Garland accept opioids for his pain relief, knowing that opioids are at the epicenter of the DOJs and DEAs modern, medical iteration of its ‘war on drugs’? At what point does he act like a patient or a law enforcement agent when receiving opioids? We can only imagine. But we surmise it would go something like this:

While Mr. Garland is recuperating from surgery, the physician overseeing his recovery would assess the surgical incision and would monitor for adequate pain relief. At some point in the clinical encounter, Mr. Garland would answer the perfunctory question rating his pain on a scale from one to ten.

When Mr. Garland responds with a numerical value, should the attending physician believe him? It would be the clinically sound thing to do. But legally, would the physician place himself or herself in jeopardy by trusting Mr. Garland? It’s Churchill’s riddle wrapped in a mystery inside an enigma.

Here you have a patient recovering from surgery who also happens to be a federal law enforcement agent – the top one at that – who oversees the very agencies that could put the overseeing physician in prison depending on the clinical decision made in this exact circumstance.

What happens when Mr. Garland says his pain is increasing? Should the physician document the presence of breakthrough pain? Or should the physician document that Mr. Garland is likely malingering and exhibiting drug-seeking behavior? Or maybe document both? Hedge against both options, just in case Mr. Garland decides at first to act like a patient and then decides to behave like a federal agent after the fact.

But this is only one decision at one point in time. For patients recovering from an interlaminar decompression, the average recovery time is a little over two days. This means the attending physician would have to review Mr. Garland’s pain management for at least six encounters, assuming three shifts per day and one clinical encounter per shift. What happens after the initial encounter?

Should the attending physician reflexively implement a tapering schedule without first discussing it with Mr. Garland? Or, to be extra safe, should the physician simply discontinue any post-operative pain management that involves opioids? Better yet, discontinue any and all prescription opioids and provide medical literature that discusses the psychosomatic nature of pain – let Mr. Garland know that his post-operative pain is simply in his head.

What about proper oversight? What if Mr. Garland monitors the number of times he’s asked to take a urine drug screen or the number of times he’s asked to repeat imaging studies? Assuming Mr. Garland stays the average number of post-operative days, should the attending physician repeat imaging studies on the second post-operative day – or just assume that Mr. Garland is in continued pain because he recently had surgery? Wouldn’t Mr. Garland chalk that up as a lack of proper oversight?

If we were in the attending physician’s shoes, we’d order as many urine drug screens and imaging studies as possible. In case, as Mr. Garland recovers, he transitions from patient to agent faster than he’s cleared for discharge. On the other hand, what if Mr. Garland suspects that the attending physician is over-utilizing urine drug screens and imaging studies? How should the physician respond in that case?

Maybe the attending physician should ask Mr. Garland what to do. In this way, the physician can claim he or she sought the counsel of law enforcement when making a clinical decision. It’s probably the safest way to go.

What if Mr. Garland decides not to act as either a patient or a law enforcement agent, but as an undercover agent? In that scenario, by asking Mr. Garland for advice on whether to adjust or continue pain management, or to order urine screens or imaging studies, is the physician failing to provide sufficient oversight?

Perhaps the physician can ask Mr. Garland what he believes the appropriate course of care management regarding his pain relief should be – but then do the opposite. In this scenario, the physician covers all bases and treats Mr. Garland the patient, the agent, and the undercover agent.

Or, thinking more realistically, the physician should just transfer the post-operative care for Mr. Garland to another unit and take a few days off. Why take the risk? After all, you can’t get targeted if you abandon your duty as a physician.

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This satire mimics a speculative clinical scenario that sadly is far too real for far too many physicians across the country. We pray that Mr. Garland recovers well and returns to work in as timely a manner as possible. But we also hope that Mr. Garland learns from his experiences as a patient and recognizes the harms the DOJ and DEA are causing physicians and patients alike.