Agraphia Medical Tragicomedy

24May/1323

An Argument Against The Poppy Seed

I know I talk a lot lately about drug seeking.  A large part of this is that I work as the community ER doctor in a small town rife with opiate and benzodiazepine addiction. It's a massive issue.

During one particularly miserable shift, I decided to catalog the degree of drug seeking behavior. I saw 25 patients.  Of those, 15 had presented to the ER for overuse of opiates. These split into three categories:

  1. Chronically on massive doses, now with new pain - one woman in particular had been prescribed around 3,000 pills in the last 12 months and "needed something stronger than her OxyContin."
  2. Came in by EMS not breathing due to an opiate overdose.
  3. Doctor shopping for narcotics, with over 2 ER visits a month for pain meds.  One patient had been seen 175 times in an ER over 5 years without ever having been to her primary care doctor, divvying up visits between local ER's so none would be the wiser.

Let us pause for a moment.  15 patients out of 25 is 60%.  That is a staggeringly high percentage of patients whose primary reason for an ER visit is related to overuse of opiates.

That night has influenced my medical practice quite a bit.  I've started to think about appropriate patient care in terms of what I would need in the same situation.  Bruise to the shoulder?  Maybe some tylenol or motrin, and a careful exam to make sure I didn't break anything.  Sprained ankle?  Ice packs and naproxen.

The truth is, my little community is plagued by addiction, which wouldn't exist without physicians to fuel it.  Patients refer to their thrice-daily Xanax dose as "footballs" or "bars". They say that they need their "hydro 10's" or "perc 10's" to get through the day - slang for hydrocodone 10/325 and oxycodone 10/325.  Inevitably they've used more than prescribed.  I look most of my patients up on our controlled substance database and I'm never surprised to find ten, twenty, thirty prescriptions for controlled substances from various physicians over the past few months.

This brings me to a case that stands out in my mind.

I had a young woman a few weeks ago who came in with excruciating leg pain.  She looked absolutely miserable, rolling around in the bed, screaming obscenities.  I finally managed to convince her to keep the "FUCKS" and "SHITS" to a minimum since she was sharing a room with a 6 year old child who looked absolutely terrified.

She was incredibly upset when I didn't provide her with pain relief - specifically in the form of intravenous Dilaudid.  Even for an ER doctor who deals with this on a daily basis, it was worse than usual.  At one point she said "it really sucks that there are drug seekers in this world. You aren't giving me pain relief because of them, and I'm a normal person.  I can't believe how jaded you've become.  You're a bad doctor."

Her controlled substance search didn't turn up much, but I still got the sense that there was something not quite right here.  I chose to give her non-narcotic pain medications.  She threw a string of curses at me when she found out.

It is hard to explain the hurt I experience in a situation like this.  I'm a nice person. I went to medical school to help people.  Given a normal patient, I will bend over backwards and do everything in my power to diagnose and treat illness and pain. At the same time, "help" does not mean "give you your drug fix".  Implying that I'm witholding pain relief just because I'm a jaded, bad ER doctor cuts down to my core.

I ended up apologizing for my inability to prescribe the Dilaudid and Percocet 10/325's that she so desperately wanted.  She left cursing my name, stating that if she had to, she would "get relief on the streets". It left a sick feeling in the pit of my stomach.

A week afterwards, I reviewed her chart.  She had been seen by one of my partners for a nearly fatal overdose.  Apparently she was living in a commune with a bunch of drug addicts and overdosed on narcotics.  The reason she didn't show up on my controlled substance database on that first visit is that heroin isn't something we prescribe.

I've wrestled with her case since then.  I know that in the end I did the right thing because I trusted my instincts.  Still, the accusation and the hatred in her eyes haunts me.

"I can't believe how jaded you've become."

"You're a bad doctor."

But I did the right thing.

Comments (23) Trackbacks (0)
  1. From this post and others, I wonder if your hospital has considered opening up a methadone clinic.

  2. Did you do the right thing? I have never been addicted to anything in my life. I am a 36 yr old college educated female who presented with a staph infection in my local ER. As I truthfully answered “7″ out of “10″ on the pain scale to blase nurse after blase nurse, I was given nothing but a local for the lancing. I was sent home with 6 vicodin. I sat there, unable to put my arm down (boil in armpit), tears running down my face in pain- pain that didn’t abate for 4 days, which I worked through by over using Naproxen. Because I was treated by so many jaded professionals, I asked them if they thought I was drug seeking. No answer. Guess they thought I was…I am on medicaid.
    Doctors with your mindset are wrong- treat first, then do your social differential DX. I don’t go to get treated and be socially judged, I’m in your ER for a snapshot of time. Treat me for that snapshot, not what you think is my movie. UNDER treatment of pain is an epidemic as well.

    • the 6 vicodin is for that snap shot. it is meant to keep the pain at bay until you can get to your own doctor and get a prescription. a local is undeniably the right choice for a lancing, after all, you don’t need an anesthesiologist with a propofol drip to do a lancing.

    • When you treat for symptoms rather than the real problem, you incite drug abuse and dependence. Patients with staph infections need antibiotics, they don’t “need” painkillers. Steps taken to help a patient survive are far different than steps taken for comfort. I agree that there is a certain balance between the two that modern medicine allows for, but you have to remember what you’re being treated for rather than what you want immediately.

      • It bothers me that freedom from pain is not considered to be part of full treatment. My incident, which I neglected to say, was on a Friday at about 6pm. No regular doctor for me until Monday. That snapshot? Not a good picture.
        I’m going to go ahead and assume you’ve never experienced a full blown staph infection if you’re saying painkillers aren’t needed. Good grief. If it involves a scapel and infection then yes, probably a lot of pain.
        Please look at the bigger picture- not everyone is a drug seeker. Some pain is very, very real. It does get under treated by jaded doctors. There are 2 sides.

        • Laura, there are absolutely two sides to this problem. I certainly prescribe my fair share of norco, percocet, morphine, dilaudid, etc. Someone with an infected staph abscess almost always gets a prescription for some narcotics for me upon discharge.

          You should also know that ER doctors don’t pay any attention to insurance status, unless it’s specifically for the question of whether or not our patients will be able to afford medications at the pharmacy. We function as the safety net for all of the US, so we see people entirely regardless of their ability to pay.

          I wrote this post specifically about this one patient who appeared to be drug seeking. While it may seem that a small prescription for narcotics isn’t a big deal, it is if it (a) results in someone getting addicted or (b) contributes to their overdose. In her particular case, I’m glad I trusted my instincts and didn’t give her anything. Those extra few vicodin may have made the different between a non-fatal and fatal overdose.

        • Laura, not to say that the pain you experienced wasn’t real or as intense as you describe, but there is still yet an even bigger picture. Doctors don’t just come out of medical school “jaded”. Doctors become jaded because of the various patients they encounter; making decisions about an array of medical issues on a case by case basis. They try to be as personal as possible using similar tactics and treatments for varying individuals. So, while yes…there are in fact two sides, is there a right way to treat both parties with an adequate amount of medical treatment without favoring one over the other? Where is the line between prescribing too much and prescribing too little?

        • Totally agree Laura. I sincerely hope that these judgmental jerks someday develop a condition in which they are in need of serious pain relief and they are sitting on the side of the fence they judge so harshly.

    • 6 Vicodin is supposed to get you through the weekend so you can follow up with your PCP. Pain meds aren’t made to remove pain, they are there only for mitigation. Too much of it only leads to dependence and that is the real danger.

      Your return to the ER over and over for a non-life threatening, albeit painful, issue makes you look like you’re drug-seeking. Follow up with a PCP.

  3. As a recovered IV drug user and also a member of the healthcare team, I am curious if there is anything in place that offers a different solution. Drug addicts and alcoholics use because we can’t stop. Yes, we initially make that decision to use the first time but over the course of months, years or even decades, we lose the power of choice. Most want to stop, they just don’t know that they can and they don’t know how. My job was not to detox people on the spot. It was to provide care for their health. One specific avenue of care is Narcotics Anonymous or Alcoholics Anonymous. I would recommend calling the local offices of each and present your experience of 60% of your patients coming in for narcotics. Maybe a few members can come hang out at your ER and share their experiences with those seeking help. No other can help a suffering addict like a recovered one.
    Good luck to you. Remember that we aren’t bad people. We just suffer from a disease that manifests our symptoms which interfere with the lives of other people. And lastly, we can and we do recover.

    • Good to hear from you, Troy. I’ve tried this approach a few times, and have even successfully sent a couple patients to NA or inpatient detox.

      Narcotic addicts aren’t bad people, by and large. They’re just people who happened to get addicted to a substance that the human body craves. Once you start treating it as a real disease I think it gets easier to deal with from a physician perspective.

      The difficulty I run into is when people present to the ER specifically for the goal of garnering opiates, inventing progressively strange stories and symptoms. Many will get harmful doses of radiation while waiting for their fix. Massive amounts of healthcare dollars are racked up “searching for a cause” when, if we were all just honest with each other, we’d be up front with things.

      In the end, we ER docs get very good at picking up on drug-seeking behavior for this reason. My whole goal is to get people to a primary care doctor who can help with detox / weaning off if possible.

  4. Zac, How do you feel about pain contracts? Do you use them at your facility?

    • Pain contracts are incredibly helpful. i find that patients come to me occasionally “willing to break the contract” because they ran out of their pain medications early (again) and they’re hurting. The immediate need for an opiate fix is honestly a sad thing to witness. Sticking with their contract will give them hundreds of pills per month, but they can’t think that far ahead. They need their dilaudid NOW because the last few percocets they had are starting to wear off.

      It’s a miserable life, honestly.

      The flip side is a very nice woman who was looking for adjunct therapies for her typical back pain, but did NOT want to violate her pain contract. That was a wonderful experience for us both. I got to try some new therapies, she left comfortable, and never a word was spoken about opiates.

  5. I have had intermittent pancreatitus for nine months with 4 hospital stays including a heart attack brought on by the pain. In my past I’ve had 6 knee operations and a ruptured artery in my calf. Since the pancreatitus I have a new understanding o pain. My previous 8/10 is now a 5/10. They haven’t found the cause but they agree that it is inflamed. In the hospital I received Dilaudid in my drip and Oxycontin orally until the pain subsided. I have a permanent tolerance to Opiates due to my many problems and avoid them so when my knee is replaced they can still have some effect. I went to the ER last month and my blood pressure was 188/120 because of the pain. It was 114/78 six weeks prior. The ER Doctor read my chart, gave me a saline drip and a prescription for Ultram and Pepcid. I threw them away and picked up a bottle of Jameson whiskey. It took about half of the bottle to knock me out. Some ER docs are just clueless about pain and I won’t bother to go next time.

  6. This issue seems to be quite complicated. True. It does seem unfair that people who have pain can’t so easily get the drugs they want or need. However, since some people continue to abuse the distribution of drugs, doctors don’t have a choice but to be careful. I don’t think it makes you a bad doctor for protecting people and the drugs they get from you. Im surprised even that this individual would still expect to get these drugs even after she knew why the fear of abuse was the reason why you wouldn’t give them to her.

  7. Hello Zac,

    I’ve missed your postings during the last couple of months. It’s great to “hear” from you again. I enjoy reading your perspectives concerning medical and social issues. I thought I might add my two cents to your most recent post, both as a patient and as an aspiring physician.

    You see, Zac. I was born with a complex genetic mutation that eventually developed into a full fledged medical connection. The name of the condition is irrelevant, but the nature of it is on topic. The condition, itself, manifests in the central nervous system as well as in the branching nerves throughout the body. Because the nature of the condition presents itself in my nervous system, I’m quite prone to excruciating neuropathy, phantom pain, ocular migraines, lower back pain and neck pain, among other types of pain. My feet and back can be an especially difficult burden on my overall health at times.

    Because my condition is highlighted as being especially painful, obtaining prescription painkillers was not difficult for me. In fact, perhaps it was too easy, because after I got them I began using them to treat the wrong kind of pain. The kind of pain that manifests itself not in the nervous system, but in the core of your existence. I was in a new town, no friends, no family, handling the burdens of a college student on my own after barely graduating from high school. Naturally, I turned to the only comfort I could find, those little pills that take away the bad thoughts in your fatigued mind and replace them with a sense of peace and relaxation.

    Like I said, I was on my own. There would be no one to catch me if I fell, nor anyone to take the bottle out of my hands should I grow to attached to it. Life didn’t improve until some years after I decided (for no apparent reason other than that I was tired of feeling nothing) to discard the empty bottle and choose not to refill it.

    That experience has changed how I view pain and medication. I still feel pain. Even with the occasional Tylenol or Advil PM, I still feel pain. And you know what? That’s ok. It’s good to feel some pain. Your goal as a doctor should not be to make sure the patient is in absolutely no pain (unless dying, in hospice or a nursing home, of course,) but to help them get better and to teach them how to better take care of themselves.

    So, what do I do to cope with my pain these days? I keep myself active and I keep myself busy. I’m now an honors student, a math tutor at my state’s school for the deaf and an active volunteer in my community. Being in pain has not stopped me or prevented me from living life to the fullest because I chose, and actively choose, not to let it.

    Feeling pain is part of being human. You are a good doctor, Dr. Zac. I mean that with the most sincerity. Keep up with the great blogging and take care of yourself.

    Sincerely,

    The Other Side of the Knife

    • Opiod addiction due to existential angst. I have spent hours trying to explain this to various patients over the years. God bless you.

  8. Hey there,

    First of all I love reading your blog. As an ms1 who is interested in EM it’s such an interesting window into the world and mind of the field. Just a quick question. How do you see the patient satisfaction thing settling in the future. Seems like docs universally hate it and admins universally love it. Where do you think the equilibrium will end up?

    Thanks again for all the thought you share.

    Nate

  9. Such interesting perspectives from all! My two cents as a healthcare provider is this: we have failed our patients. It is our jobs as physicians and nurses to explain to the patients our goal for their pain control and the ramifications of not following the directions of prescribed narcotics and all medications for that matter. For example: I occasionally take care of patients who are constipated and are requesting pain medication for the subsequent abd pain. On further exploration we find that they require narcotics chronically for pain control, and that no one has ever explained to them the importance of stool softeners while on these medications. When we explain that they are not going to get narcotics for the pain they are experiencing in their abd they become extremely angry; so now we have a vicious cycle.

    If we do not get control of the prescription drug abuse in this country soon we will soon find ourselves with narcotic clinics for simple things like percocet, because people cannot be trusted to take their pain medication as prescribed.

    Always enjoy your thought provoking blog Dr. Zac. Keep it up!

  10. Interesting; here is a thought,
    So, This patient with a clear verifiable reason for pain, doesn’t deserve in house pain relief? I’m not talking about a take home prescription, but nothing to control pain while in the ER?

    Her past overdose should not have any bearing on the physical pain she felt at that moment…….

  11. I realize this post is several months old but I just wanted to give you a thumbs up for your willingness to do what is best for a patient rather than what they want. My best friend died after struggling for years with an addiction to prescribed pain meds and I know all to well some of the things people will say or do for a script.
    With that said I also want to voice my frustration with my own condition. I suffer with severe migraines and there have been many times when my meds didn’t work. The only option I have in that situation is a shot. My frustration comes from one of the 2 hospitals in my smallish hometown. They have access to my records, my doctor is affiliated with them, yet I was still accused by a nurse of drug seeking because I had averaged 1 ER visit every 3 weeks for around 3 months or so. I had to ask for toradol, knowing it was not a narcotic and that it worked sometimes with a migraine but not always. They were more than willing to give me that shot. Fortunately it worked that time. It’s very frustrating to have a condition that may require stronger meds because of the abuse that is out there. It’s also embarrassing and humiliating to have such a condition and be accused of seeking drugs. Yeah, there are times I seek stronger meds, whatever one will relieve the intense pain, vomiting, slurred speech, confusion, imbalance, and dehydration. People have thought I was drunk while I was in the middle of a severe migraine attack and to have to deal with the pain while at the same time being accused of seeking drugs is not an easy task for someone who can barely think from the pain.
    So I do understand both sides. I watched my best friend slowly kill herself with a prescription drug addiction and was powerless to do anything except support her those few times that she went into rehab. And yet I have a condition that has often seen me in the ER seeking a shot for relief…


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