Agraphia Medical Tragicomedy

8Jun/13Off

How To Fix The Prescription Drug Problem

As I am wont to do lately, I've been thinking an awful lot about prescription drug abuse.  My last shift, I saw a guy who got in two car wrecks in the space of a few hours while taking his 2mg prescription Xanax "bars" six times a day as prescribed.  I saw a woman with over 300 prescriptions (each of which contained 30-120 individual pills) for opiates and benzos in the past 3 years from around 40 different doctors.  Another woman lamented that she ran out of pain meds just in time for the weekend, and her primary doctor wasn't going to give her "Roxi 30's like I asked for" - street slang for oxycodone 30mg, the highest-value street drug currently on the market.

I've said it before, and I'll say it again.  Prescription drug abuse in this country is a massive issue.  There were over 16,000 fatal overdoses in 2010 and the number continues to rise.  More people are dying from overdose than from car wrecks in some states.  While I care about alcohol abuse and illicit substances to a lesser degree, I'm fixated on prescription abuse because it is preventable.  One source states that the USA uses 80% of the world's opiate supply and 99% of the world's hydrocodone.

There are several issues at play.  One is that no physician wants to be confrontational if they don't have to.  I think ER docs do it by necessity, but primary care doctors can't afford to antagonize their patients - and thus, jeopardize their revenue stream.  When someone comes in and has been on Xanax three times a day for the last 10 years, you throw up your hands and write the script plus refills.

As the staff members at the emergency dental treatment Perth clinic exclaim adamantly in their posts, this particular behavior needs to stop.  We ER docs see the overflow from the primary care physicians, the psychiatrists, and the dentists who turn into unwilling pill mills.  As long as there is no oversight, this will continue.   Aside from the nebulous concept of "doing the right thing", there is no reason for any individual provider to wean patients off these meds.  In fact, the opposite is true - patients would simply leave your practice and go to another provider who will give them their fix.

I believe the solution lies with the state medical licensing board.  Here's my plan.

  1. The state board sends all physicians an alert "Your license may be in jeopardy!  Statewide, physicians must come up with a plan to wean all of their patients off prescription opiate medications and benzodiazepines, unless there is a documented and valid reason to keep doing so.  You have 1 year to comply."
  2. At the six month mark, remind physicians that they are coming up on the deadline. Give them a progress report.
  3. At the year, patients on chronic Xanax, Klonopin, Ativan, Valium, Percocet, Oxycodone, Vicodin etc have all had this discussion with their primary doctor "The government is cracking down on physician controlled substance licenses.  Neither myself nor other physicians can prescribe controlled substances on a recurrent basis any more."
  4. Any physicians not playing ball get 3 notices, then lose their controlled substance license.
  5. The end goal is to have meds prescribed as intended, with short courses written for acutely painful or stressful episodes.  Long-term opiate management would be tightly restricted to the setting of cancer, fractures, and a few other conditions.  Long-term benzo use should be flat outlawed.

I'd love to hear your thoughts.  Soon here I'm thinking of marching on Capitol Hill.

27Mar/13Off

The Patient Satisfaction Dilemma

I saw an exceptionally malignant patient with back pain a few days ago.  Readers who work in an ER know exactly what I mean just from that statement; for my lay readers, let me try to paint a picture.  He was a 50-something, shabbily dressed guy in somewhat of a constant state of disrepair.  There was a musty odor of tobacco about him, and when the nurse entered the room he sneered "Oh, there you are.  So there IS someone actually attending patient needs today.  Get me a damn soda, I'm thirsty."  He had been triaged, registered, and taken to a room within 25 minutes of arrival.  His wife piped in, "Make it a Coke for him and a Mountain Dew for me.  We don't do Diet."

I walked in the room to a hostile environment.   His wife was tapping her foot on the floor impatiently, lips pursed, and apparently we were fresh out of Mountain Dew.  He had his arms crossed and began to lay into me before I could say a word.

"I want an MRI.  I hurt my back lifting something a couple hours ago, I've had a bulging disk before, and I've been waiting now for the better part of 30 minutes to see ANYBODY who is competent around here."

I took a mental breath, calmed the raging inner demons, and introduced myself.  I apologized for not seeing him earlier as I had been performing CPR in another room and broke away just as soon as I was free.

I'll cut the story short here and get to the chase.  He left the ER with a diagnosis of back sprain sans MRI, shouting at staff, extremely angry... but it was clear from our first interaction that this was inevitable.  Interestingly, he didn't come to the ER for pain control - he came because he wanted an MRI, and was livid that I wouldn't give him what he wanted.

This gets to the crux of the matter at hand.  There has been a rising emphasis on patient autonomy in medicine, a deliberate shift from the paternalistic attitudes of physicians of old.  It is one of the four central "pillars" of medical ethics; Autonomy, Beneficence, Non-Maleficence, and Justice.  Most of the time, it is a good thing.  I involve patients and family members on their medical decision making as often as possible.  If I'm waffling about admitting a patient to the hospital, I'll ask them, "do you feel comfortable going home tonight?  We can try home therapy first and you can always come back if you aren't doing well."  I am often surprised by how adept patients are about making these decisions for themselves.

There is, however, a group of patients we'll call Generation WebMD, who think that 5 minutes of Googling has given them a provisional electronic doctorate.  This guy got it into his head that he wanted - no, needed - an MRI to diagnose his back sprain and wouldn't take no for an answer.

A scenario like this plays out every minute of every day in every ER across the country.  I have had furious mothers physically escorted from the premises by security guards over whether or not their child should get antibiotics for a cold.  Drug seekers have thumbed their switchblades at me when I inform them I will not be providing them with their fix.  One of our regular COPD patients has a strict "only three breathing treatments per day" policy to prevent him from overstaying his welcome, happily puffing on albuterol while lighting cigarettes and tampering with the smoke detector.

It's a huge issue.  Physician reimbursement nowadays is often linked to patient satisfaction scores.  Physicians at a neighboring ER, for example, have 25% of their entire salary directly tied to phone surveys.  That's a huge incentive to make sure people are happy - and people are happy when they get what they want.  Unfortunately, what people want when they come into a medical setting is often not what they need.

Here's the thing.  If all you do is constantly acquiesce to patient demands to make them happy... well, you aren't really a doctor, are you?  You're just a puppet medical license with a DEA number for hire.

I got into a huge argument with a woman a few weeks ago about antibiotics for two days of sinus pain.  She started screaming so loudly at me that a police officer walking down the hall peeked his head in.  She finally asked me a simple question, "JESUS, doc, why are you being so damn obstructionist about this?  All I want is some fucking AMOXICILLIN for my sinusitis!  It has worked EVERY OTHER TIME. It's not like I'm asking for a prescription for medical marijuana!  WHAT IS THE HARM?"

I've thought a lot about her in the past few weeks.   Every single patient I have seen dying of multidrug resistant bacteria, every news article I see about superbug TB, every case of clostridia difficile colitis - I have mentally told her, "This.  This is the harm.  The harm comes in physicians prescribing things that aren't needed, doing tests that aren't indicated, giving therapy just to say we did.  One day we will look back from the brink and realize we should have been more careful."

I could go on, but I've made my point.  It is so easy to roll over and give people what they want.  I fight this temptation every single shift.  Mom wants amoxicillin for her kid's "ear infection".  Guy wants Vicodin for back pain.  Family wants me to "do everything" for the 95 year old demented nursing patient.

With a click of a button I can easily do all these things, even when I know I shouldn't.  And I'll get paid more.  And I'll avoid lawsuits.  And my patient interactions will be far more pleasant.  I suppose in the end, I try to do the right thing instead of the easy thing because I firmly believe that my duty is to take care of my patients.

And sometimes, despite violent opposition, that means simply saying no.

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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