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:
- 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."
- Came in by EMS not breathing due to an opiate overdose.
- 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.