Imagine this. You are glancing through the obituaries of your local newspaper and you see the face of a young person who is vaguely familiar. You start to read the column. It is about a man in his 20s. Then you remember: yes, I did an appendectomy on him a few years ago. Nice young man; I saw him back in my office 2 weeks after surgery and he was doing great. You keep reading, wondering how he became a headline in this particular part of the newspaper. The article does not say how he died. Something in the back of your mind bothers you and makes you open his record in your electronic medical record. There it is in the emergency room note: he died from an opioid overdose. Your pulse accelerates a bit. Did he use opioids before surgery? No. You check to see whether he was given a prescription for opioids after the appendectomy. Yes, he was: thirty 5-mg oxycodone tablets.
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Barth RJ, Waljee JF. Classification of Opioid Dependence, Abuse, or Overdose in Opioid-Naive Patients as a “Never Event”. JAMA Surg. 2020;155(7):543–544. doi:10.1001/jamasurg.2020.0432
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