Agraphia Medical Tragicomedy

24Mar/13Off

Diversion

In our little community hospital, opiate addiction is rampant.

It is a well-known problem among the ER crew.  The majority of our county is cared for by around 20 primary care doctors, and most of them are pretty sharp.  There are a few, though, who are pill pushers.  These guys contribute massively to our opiate problem, and on nights and weekends, the ER gets stuck with the flack.

A middle aged woman came in last night for a chief complaint of "back pain".  Just as a protip to you nascent drug-seekers out there - if you want opiates from from an ER doc, don't use back pain as your excuse.  Every single ER physician in the country has an immediate, gut reaction when they see "back pain" as a chief complaint on the tracking board.  Burned too many times, perhaps.

Walking into her room, I couldn't help but raise an eyebrow.  4'2", 280 lb, stretched out on the bed with her arms and legs askew, she looked frankly comical.  She was playing a part, perhaps one she had seen on TV of the patient in distress.  It didn't help that she was completely calm before I walked through the door, but started moaning and shouting when she realized someone had come to see her.

Her: "Aaaoohhhhh, my back!  It's my back, doc!   I need Percocet!  Awwwwoooohhh!"

Me: "And it's nice to meet you also, ma'am.  My name is Dr. Zac.  What brought you in today?"

Her: "AAAaaaahhh!  I fell... a week... two weeks (here she becomes short of breath)... maybe a month... ago... at Wal-Mart.  I can't WALK!  I haven't been able... to WALK! For MONTHS!"

Me: "Sounds miserable.  What have you taken for pain at home?"

Her: "I don't got... I don't got nothing but Tylenol and that ain't TOUCHING the pain!"

In my state we are extremely fortunate to have a scheduled drug database search.  Not all physicians in all states are so lucky.   To be honest, it has been a complete eye-opener for me in some cases - I had no idea how serious the opiate prescription/diversion/overuse problem was until I started really looking some of our patients up.  In this particular case, she had 120 Vicodin prescribed to her 7 days earlier, but neglected to mention this to me.  I went back in her room after looking it up.

Me: "Ma'am, what exactly happened to the Vicodins you filled from Rite-Aid last Wednesday?"

Her (sheepish): "What?"

Me: "The Vicodins.  Where are they?  You're in the ER, asking for pain medications, after getting 120 pills 7 days ago.  By my count, that is 40 grams of Tylenol - along with the opiates - that you've ingested in a week.  If you've taken all those pills, you may have serious liver damage.  What happened to all those pills?"

For lack of a better phrase, she immediately sobers up.  The antics, the capering, it all stops.  Suddenly the truth comes out.

Her: "Well... I'm behind on rent."

Me: "And?"

Her: "I sell my pills every month to my grandkids.  It nets me a few hundred so I can pay my bills, but I had a bad water leak this month and had to pay out of pocket for a plumber.  I'm sorry, doc.  I'm on fixed income and this is the only way I know to support myself."

I'm not used to this kind of honesty from patients.  Some of it is that recently, I've been more comfortable asking patients about their medical misadventures.  As a medical student and resident I was somewhat more reticent.  Nowadays, someone with 20+ ER visits in the last year, each with an end-goal of obtaining Vicodin or Percocet?   You need to see a doctor who can manage your pain - or your addiction.  I'm happy to refer you to detox if needed, but I won't add fuel to the flame.

Frankly, I felt guilty reporting her to her primary care physician, although I knew it had to be done.  Opiate overdoses have tripled since 1990. This cannot happen without the help of prescribing physicians.  I shudder to think of what her grandchildren were doing with 120 Vicodin per month.  Who knows, maybe her family doc would have stayed blissfuly ignorant for years, blindly supplying the kids of our county with Vicodin for their parties... and my patient would have kept her apartment.

These decisions, they give me grey hairs.  Not because I made the wrong choice, but because I never knew this sort of thing existed in the world until I started this job.

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  1. You’re a good person with a good moral compass. As an RN, I respect you.

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