When it comes to opiate drugs, like morphine, there is a bitter debate between patients who are in chronic pain, and the doctors who are vilified for under or over-prescribing these medications.
But there are some other subtle influences that push doctors to prescribe these drugs, in some cases inappropriately. An ER physician talks about the issue, saying, “when dealing with a patient who is in pain, or appears to be, it can be impossible to sort out when a patient needs opiates for legitimate reasons, and when it is merely feeding a long term addiction. We are trained to provide comfort and relief from suffering to our patients, and we generally will err on the side of treating pain, rather than withholding addictive medications.”
There is also the pressure to provide “patient satisfaction,” and indeed, low scores in this area can place a doctor’s job in jeopardy. Taking a stand against those who inappropriately request opiates will result in low patient satisfaction scores, and “will often times result in arguments, profanity, and calls and letters to administration.”
What’s the answer? Perhaps a little less reliance on these scores, since a good patient satisfaction score is not necessarily correlated with proper medicine.
Related posts:
- Should some doctors be restricted from prescribing narcotic pain medications?
- Should patient satisfaction influence physician compensation?
- Medical ghost-writing influences doctors to prescribe more drugs
- Do doctors who use social media prescribe more medications?
- Who are more likely to inappropriate prescribe antibiotics?
- Are generic drugs truly equivalent to brand name medications?
- Sued for side effects
{ 26 comments }
Kevin,
Not only are the pressures from the administrative side real, the repercussions from being an outlier can follow a physician way past the walls of that ED. The hallowed patient satisfaction survey is wedged so firmly into the corporate culture of most organizations that even the CEOs pay is directly tied to overall satisfaction, not to mention every middle manager in-between. No wonder when the patient calls and raises Cain, regardless of the legitimacy of that claim, the administrative prerogative if to side with the patient! Why let a little thing such as the appropriateness of care, or GASP- provider satisfaction, i.e. lack of burnout from feeding addicts their candy and empowering ED physicians to actually withhold narcotics when appropriate, get in the way of the CEO’s bonus check that could pay for 5 ED physician salaries.
To be fair, the other side of the coin is just as disturbing. Jaded providers get so gun-shy they fail to provide adequate quantities to legitimate patients in pain to get them through their acute episode. Because they see so many diverters, they write insanely small #12 lortab 5mg scripts on a Friday night to a woman with a broken arm and expect that to last until she can call the orthopedist Monday morning to get it fixed, only to have her resurface on Sunday in uncontrolled pain.
As a provider, I would like to think that the solution may actually be in effective e-prescribing modules, linking all real time pharmacy data and ED physicians. This is one case where technology in the right place at the right time with the right purpose can help both the patient and the provider. Physicians can demonstrate easily their justification for not giving someone their 5th script for a controlled pain medication in as many days and non-abusers can get appropriate treatment, a win-win that doesn’t seem to occur very often in medicine these days.
dockj
Dealing with chronic pain is a significant issue but one physicians usually deal with if they start at the initiation of treatment. The unnerving problem comes when a new patient arrives on multiple high dose opiates and sedatives. After struggling with this problem for many years I finally took a tack that improved my comfort level and at the same time treated the patient fairly. I tell such patients I am willing to refill these prescriptions if they have the appropriate specialist agree that that they are on a proper regimen. Until this has been done I can not prescribe refills. If they balk that they are running out I told them they should have taken care of this with their previous provider. All do not walk out of the office but do make appointments as advised and if their regimen is approved I have documentation of rationale for their treatment.
Glad to see this issue is being discussed by someone…I’m even more concerned that if I refuse to prescribe an addict a narcotic, they and their friends will flood doctor-rating sites with negative comments about me, scaring my other patients away from me. No good deed goes unpunished, I suppose!
I’ve been saying this for years. Administration has *never* had a good answer for me as to how to control for the encounters where doing the right thing and practicing good medicine results in patient dissatisfaction. Unfortunately medicine has been allowed to become such a business, that we lost something precious when we stopped thinking of people as patients, and started treating them like customers.
Should doctors care about how satisfied their patients are with their treatment? Absolutely. But the way to do that is hire physicians who demonstrate empathy, but give the tough love when it’s needed. Give us our profession back. Remove the “very good care” stickers from everything, and stop coaching the patient to fill out those *worthless* Press-Ganey survery (you want to talk about a scam… how much money would be saved by not paying those yahoos for worthless information?).
This extends to issues beyond narcotics. Patients who demand MRIs even though it’s not indicated yet. Those hard smoking cessation talks. One of the reasons healthcare costs are exploding is because power has been taken away from physicians, and if we become too interested in their “satisfaction” we just give them everything they want.
We need to stop enabling the patients who want to treat the hospital like Dillards.
These pt satisfaction surveys are out of hand. If I deny drugs to a drugseeker the hospital calls them back and asks if they were satisfied. Of course they weren’t satisfied. They came here for narcotics to use or sell and didn’t get them.
We also have to make sure we treat legitimate pain. Sometimes it can be impossible to sort out and you give the pt the benefit of the doubt and hope and pray that the drugs you presxcrobed don’t get into the wrong hands and cause harm.
No wonder ER doc’s “burn out” at a very high rate.
dikdoc
In my organization, a frequent complaint by patients to administration is not getting enough pain meds. This results in oversight and occasionally, discussion with the providers and paper trails. The easiest path is to give the patient what ever they want and send them on their way. But… that ain’t right.
One answer might be screening for alcohol and other drug misuse. The CAGE for adults and CRAFFT for youth are quick and easy to give, even at intake. Since most people who misuse drugs (or addicted to them) almost always have an alcohol use disorder, then screening for alcohol misuse will probably catch many who want to get a prescription for their habit. Plus, screening in the ED also helps in treatment, needless to say.
Wholeheartedly agree with dockj. There is a website here in Illinois that tracks controlled substances prescriptions which has helped us to identify people who abuse the system.
I was surprised that narcotics are routinely prescribed for use after oral surgery, even though the soreness was manageable with cold packs (and it is best not to dull the pain completely, because it serves as a useful signal to be gentle with it and not eat chewy things too soon). But then it seems that most people just want the pain to go away completely immediately, so they expect narcotics for any kind of pain whatsoever. Rezmed09’s comment seems to match up with this.
Treating *acute* pain episodes with truly effective medications in adequate amounts seems like a reasonable choice – as compared to leaving the patient with little choice but to (perhaps) resort to ingesting large doses of ethanol and/or NSAIDs (at the expense of (potential) hepatic and renal damage) in an attempt to address their pain arising out of a physiological origin.
It does not seem unreasonable for patients to desire efficacious treatment with medications yielding high dose/response curves that are (relatively) less toxic than NSAIDs, or necessarily unreasonable that they might provide negative feedback if their pain is under-treated …
The relevant medical issues surrounding *acute* pain are not (physiologically) pharmacological or toxicological. The relevant policy issues of prescribing opiates/opioids arise out of matters of socio-political, legal, economic concerns (in addition to assessments existing in the realm of the art of psychiatry made on the part of physicians more centrally employed in the practice of the science of physiology).
More locally, the prospect of patients noting what does, and what does not, address their (subjectively perceived, and thus non-reducible) experiences of pain, and correspondingly communicating their experience and wishes to the physician, may present a troubling threat to the physician’s sense of primacy in decision-making.
If we expect intelligent patients to communicate honestly with physicians regarding their actual experience in the perception and relief of their pain arising out physiological origins, physicians should be willing recognize the subjective differences in the perception and effective relief of pain that is experienced on the part of individual patients, and acknowledge the actual pharmacological and toxicological truths surrounding analgesic therapies – without resorting to bureaucratic rationalizations and manipulations unrelated to the patient’s interests and desires, and exercised (instead) as strategic actions.
The definition of the operational terms (”over-treatment” and “under-treatment” of pain) are themselves subjective and strategic, and not (in themselves) objective absolutes.
In matters of *acute* episodes of pain on the part of the patient, such rhetorical strategic devices seem misplaced and self-serving as ways of exercising control over competent and intelligent adult patients.
Patient acquired knowledge (including in the matters of the treatment of pain) should be welcomed (and not discouraged or penalized). If we as physicians are to expect more than infantilism on the part of the patient, we must provide more than an exaggerated or convoluted paternalism in our interactions as physicians with them.
Intelligent and competent adult patients are capable of (and likely to reasonably engage in) the questioning of such strictures. Rewarding such knowledge and concerns with suspicion and adversity only degrades the possibilities for honest and meaningful doctor-patient communications and interactions surrounding the patient’s pain, and the possibilities for the adequate and safe treatment of such pain.
On a physiological and toxicological basis, it seems that the least desirable effect would be one that results in patients addressing their *acute* pain by means of large doses of *ethanol* and/or NSAIDs. The rest is political and strategic – and with results more commonly at the expense of the quality of patient care than with results at the expense of the physician’s career, or (as duly noted) the medical-industrial CEO’s monetary bonuses.
If we choose to don the robes of the priest or constable in the course of the practice of physiological science, perhaps we owe an honest admission to the patient that our concerns arise more out of societal influences of the State, Employers, and our own personal interests – as opposed to the competent adult patients’ experiences of (and the safe and efficacious relief from), their pain.
.
Patients with true pain find it hard to spend 3 to 5 hours in an ER. If you have a patient that is over anxious, normal blood pressure, and all they can talk about is the drugs that have helped in the past 7 out of 10 are drug seekers and I would bet a pay check on that. Patients that are teary eyed, above normal blood pressure and don’t really seem like they want to be there are in pain and need help. Doctors on the other hand have the DEA who don’t know Jack about medicine telling them what, when and how much to prescribe. The whole darn system is screwed up if you ask me.
RBcabledoctor
Let’s break the logic down here: patients in pain go to the doctor and pay good money for treatment and 9 times out of 10 will not receive adequate treatment for their pain. They then sometimes justifiably file a complaint about this, and you can’t understand why?
Let’s try this exercise: You bring you car to a mechanic for an oil change and tune up. He agrees to do the work but fails to do so, but still expects to get paid the full amount. Are you going to pay the full amount without complaint, or are you going to file a complaint or take some action to recover your money? I suspect that unless you’re a pushover and a sucker, you will opt for the latter.
Why then, should a patient just shut up and pay and not make a complaint when he comes to an ER in severe pain, forced to wait for hours in agony while some pig ignorant doctor considers his ability to do so a sign that he is not really in pain, only to be denied any treatment, labeled a drug seeker because his blood pressure is normal, and handed a bill for $2,000 for nothing. People aren’t paying you for ignorance and a personality assessment. They are paying for treatment. If you accept payment for a service with no intention of providing the service, you are a fraud and a thief.
You a also a fraud and a thief if you think giving someone 10 5mg Vicodin for a $2,000 ER visit constitutes “treatment.” When a drug that should by natural right cost mere pennies per pill because it is as cheap as dirt to make it, ends up costing $200 a pill when a patient is forced to go through the medical industrial complex to get it, that is thievery and extortion.
And you have the nerve to call drug seekers “scammers.”
It’s amazing, the self absorption here. You have all kinds of bogus, unscientific, ad-hoc rules of thumb to determine who does and does not deserve to get their money’s worth when it comes to pain treatment, and you believe your self-created rules with religious certainty and have no doubts, but if anyone tries to establish some criteria by which to judge your performance in doing the job you are paid to do, you can’t tolerate it.
How dare they judge the judges!
Judging by the sheer ignorance that always surfaces from the medical profession in any debate over pain treatment, I should think you are not being evaluated near enough as you should be, if such primitive attitudes and behaviors are allowed to go unchallenged by those who hire you.
The doctors posting above seem awfully dismissive of patient satisfaction surveys… as an organizational scientist and also as a 20-year chronic pain sufferer, I have issues with that. Doctors need feedback just as all of us do in our jobs in order to perform to the best of our abilities. While doctors may need a bit of egotism in order to make some of the life and death calls they are asked to make, there is no reason they shouldn’t be called to task when their performance falls short. Patient satisfaction is and should be a measure of physician performance. That said, it obviously should not be the only measure. Who else is going to let you know when you’ve missed the mark? I have received both very good and very bad care from various physicians and specialists, and welcome the opportunity to provide feedback on both. There are a number of poor-quality physicians who will continue to work in the system and provide inadequate care or pose hazards to their patients because no one ever asked their patients about the care they received. An example that comes to mind is the gp who suggested having children might get my mind off my chronic lower back pain, or otherwise to get a dog. Great idea- why didn’t I think of that.
If you make a call in prescribing pain meds, you should have the facts to support it. Those facts, as well as the assumptions you made when making the decision, should be in the patient record. The record supports your standing when someone comes back with a question or issue, and if the decision was a good one, you can show why. If not, there is an opportunity for a learning experience- I’m guessing even doctors need these, no matter how long you’ve been in practice…just like the rest of us.
Chronic pain issues and the use of narcotics over time have been clearly demonstrated to be significantly different from acute pain issues; somehow, too many physicians still don’t know this, or what to do about it in practice. Model guidelines exist to support decision making regarding the prescribing of pain medications. Good policies help to protect both the patient and physician. If the facility or office you work for does not use, support, or follow through on guidelines for controlled substances, or you are dissatisfied with the procedures, that is the perfect reason to get involved in the policy-making process. I try to make it a rule not to complain too much about something unless I’m ready to make an effort to change it. If you don’t like the status quo, get involved.
It is certainly true that treating chronic pain issues with opiates/opioids can differ from their application to acute pain issues, and potentially become a more complicated and problematic matter for the patient (the individual ostensibly being served with the assistance of the physician – and not the other way around). These realities cannot be ignored, and (should) be addressed by the acquisition and communication of accurate and honest pharmacological information by both physician and patient.
It is here assumed that it is incumbent upon adult patients (as well as upon physicians) to take responsibility for their own personal choices and actions – free from stooping to arguments of “victim-hood” at the hands of any other persons, organizations, or agencies within society.
The (rhetorical) “shoes” that patients suffering (acute, and especially, chronic) pain stand in are quite different from those worn by physicians (who exist merely one rung above the patient in a largely private for-profit “medical-industrial-complex” that all too often prioritizes monetary assets/liabilities, as well as drug controls imposed by the State, above the interests and concerns of those patients).
While it may be true that, “Model guidelines exist to support decision making regarding the prescribing of pain medications” (-glaxygirl), I don’t believe that it is true that any *uniform* applicable policy exists, (save for), “Doctors on the other hand have the DEA who don’t know Jack about medicine telling them what, when and how much to prescribe” (-Russel).
This unfortunate state of affairs leads many sufferers of pain (acute as well as chronic) who have lived to regret any once-held belief(s) that “doctor” (always) “knows best” to (understandably) develop a sense of profound cynicism surrounding their experiences with physicians who seemingly place the interests of the State, their Employers, and their personal careers above the interests of the patients who (whether out-of-pocket, via insurance, or, as well, by sheer physical suffering) “pay the price” for treatment regimens – the nature and duration of which are decided by seemingly everybody *except* the (paying) patient.
The unfortunate result is a system where the parameters involved all too often become political (including monetary and legal concerns) as well as strategic (self-serving professional and bureaucratic rationalizations unrelated to physiological or pharmacological fact) – with the patients desires and concerns taking a back-seat at the far rear of the (rhetorical) “bus”.
For physicians *ourselves* to “… get involved in the policy-making process” (-glaxygirl), physicians must face the fact that we are (largely) held by our society’s health care system in a position where professional compensation may well follow in inverse proportion to the explanation and exercise of our most closely held moral and political character (independent of the particulars of such personal character).
Whether the reigning societal “flavor of the day” be what is declared by some to be (either) the *under-treatment* or the *over-treatment* of pain using opiate/opioid analgetics, I believe that physicians should face and acknowledge the following truths where it comes to matters surrounding drug controls and their patients:
“The physician in the middle, when faced with a request for medications which may relieve pain is free to accept or reject it. Either choice is perfectly legitimate. What is morally illegitimate is the physician allowing themself to be seduced by economic and political enticements (which we can see clearly may arise out of the patient’s, as well as arising out of the State’s, specific interests) into abandoning their role as healer and betraying their ethical obligation to the patient, and assuming instead the role of referee – arbitrating the conflict between the patient who wants a powerful analgesic and the state who wants to withold it from them.” …
… “The doctor who assumes this Solomonic role – and most practicing physicians do, the practical circumstances of their lives leave them little other choice – victimizes his client qua patient, and compromises their own integrity as a healer. The physician is pulled and pushed, with blandishments and threats, to abandon his traditional allegiance to the patient, stop their hopeless struggle to to stem the onrushing tide of the alliance between medicine and the state, and become a double (or triple) agent – allegedly serving the patient, actually taking orders from the state, and still looking out primarily for themselves.”
-Thomas Szasz, Professor Emeritus of Psychiatry, SUNY
Without acknowledging and finding the courage and conviction to correspondingly act as physicians upon these foregoing truths, the patients’ best interests will forever take a back-seat to the personal interests of physicians, administrators, insurance companies, and the State. Thus, a personal responsibility incumbent upon physicians *themselves* – and not the “usual suspects” (patients, administrators, the State, etc.) – clearly exists …
.
When in training and studying the mysterious phenomena we call ‘pain’ I recall being taught the following maxim: Pain is what the patient says it is. This predates the 1-10 scale but still holds promise for the provider to comprehend what the pt. is trying to say. I maintain that the ED is NOT the place for those with chronic pain to secure medication. A loved one of mine visits his doctor at a designated Pain Center every three months. He has been a patient there for over three years. Occasionally he will require a cervical epidural injection of kenalog/lido and his doctor (one of a group of anesthesiologists) performs this. His chronic pain (exacerbated by multiple sclerosis) is treated with plain oxycodone 5mg which he takes four times a day. He is given a 90 day supply when he is seen at his three month intervals. A nurse practitioner does intake and review and writes the RX. He has an opiate agreement on file which names the pharmacy (only one) where he fills his Rxs. He NEVER needs to visit the ER because his chronic condition, like all other chronic conditions, is managed by a physician who knows him long term and knows he is NOT a drug seeker but rather a patient suffering chronic pain who needs and thankfully recieves proper treatment from a caring, knowledgeable physician/surgeon. Going to the ER for chronic pain management is unwise and a poor use of ER services.
LastoftheZucchiniFlowers, That sounds all well and good except on a weekend when the pain specialist is not in his office or is out of town with no one to take his calls. The chronic pain suffer comes to the ED with his medications and medical records in tow because he has done something to exacerbate his or her pain to the point the medication they are given for their base line pain will not begin to touch the pain they are having at that moment in time and most likely will have for the next several days. The good doctor looks over the records and looks at the pain medicine the patient has on hand and says you have pain medicine I don’t see why you need more. At this point the doctor is not thinking this medicine is just enough for a 30 day period you are not given extras for such instances and the ones you are given are not strong enough to address an injury to a 35 year old L4,L5,S1 fusion that has impinged nerve roots at L4. He gives you a small injection of Ketamine and put you on bed rest until Monday when you can reach someone at the clinic. You go home and suffer excruciating pain the remainder of the weekend because of an opiophobic doctor who thinks you have traveled 35 miles one way to get some cheap buzz.
I realize all doctors would not do this but there is a great many that would, this has happened to me on 2 occasions over a 3 year period because I try to avoid ED as much as possible even though there have been times I should have went but I did not because of the long wait and having to convince a hard nose doctor I am a 50 year old disabled Veteran not a 20 year old with a sprain ankle who could probably get by with a ace bandage and a couple of asprin. Opiates are not the evil that the government and some of the old school doctors would have you believe. It has been proven that chronic pain patients get addicted approx 3% of the time if you could take away their pain you could take away their meds after an appropriate taper.
Were not the enemy merely a innocent bystander stuck in the cross hairs.
Russell – these ‘breakthrough’ events should be discussed with and managed by your pain specialist so that WHEN the weekend comes and he is ‘not in his office’ and the worse case scenario occurs, you are covered. Patients have a responsibility to anticipate their needs, since we know ourselves best and to make preparations for our needs. I don’t blame ER docs for being none too sanguine vis a vis narc seekers because this is where they show up AND they get in the way of real emergenies. So do a lot of other non-emergent ED patients. The disposition and empathy of ED are a direct reflection of misuse of their workplace. And do not misunderstand, I am in full agreement that people in pain must have their pain alleviated – just don’t expect the ER doc on duty to be your patient when you show up there with your saga. He doesn’t know you and does NOT want to start handing out RXs for scheduled meds to people who are ambulatory and appear hale and hearty. I realize that some chronic pain pts fit this description, but Russell, the ER doc is NOT your doctor. Please prepare for emergencies and know that when breakthrough occurs you will need to be prepared. Chronic radiculopathy is a bear, I know, so take some well intentioned advice and stay out of the ER when it flares and preplan with your pain doc. He/She will help you – trust me. BUT DON’T WAIT for when they are off duty because they don’t really have pagers. Remember, they’re usually anesthesiologists with busy OR schedules as it is. If you are lucky – and your pain specialist knows you well, he’ll likely give you a phone # where he can be reached. My uncle (mentioned earlier) has HIS pain doc’s home # but in three years he has NEVER called him at home. He says something about just knowing that he CAN is relief enough. Nice thought and good luck to you in your search for freedom from pain. Whether it be physical and/or psychic pain matters not – both types will sap life’s joy leaving hopelessness in its wake. Whatever you do, DON’T take so much medication that you stop breathing. Sounds silly but it happened EVERY NIGHT across America and NO DECENT PHYSICIAN wants to be mixed up in the drug overdose death of a patient they don’t really KNOW! So cut them some slack and get proper care.
Lastof:
Wow- really, you don’t seem to get what Russell was saying…you ARE right about needing to plan, BUT all the planning in the world doesn’t account for every instance that arises…even those of us who do work closely with our doctors and managing our pain for a decade or more are struck by surprises- more than breakthrough pain, sometimes completely new twists in our battle. Even with every intention to plan on the part of the patient and their pain management team, there has to be a plan for people such as us in the ER- God knows we don’t want to be there…
Well, let me tell ya something; here I am–a 66 year young full-time employed, law abiding great-grandmother of one!! And I am damned mad, angry, frustrated and, oh, how about pissed off?! I have a very dear best friend. My best friend is a young man 21 years my junior. In 1995 while mowing his mother’s property, he got down from the tractor to move something out of his way and the tractor rolled over on him, completely disintegrating in many pieces, some never to be retrieved, his L-4 and L-5, so they are completely missing. Due to this injury, in one years’ time, he was told that he could never go back to work (as a Court Reporter which he loved), he would never walk and he had to have surgery to remove the splintered vertebra, some too close to vital organs to be removed. He owned his own business with his mother and built his own home at the age of 24, after selling the first home he bought at age 18. He bought that home in order to rent it out to four other college students so that he could pay for his college education. When his doctor told him that he would never work again, his wife of 6 years left him taking their two year old daughter, his only child. A year later, my friend had to sell his camps on the Gulf, his boats, his Porches, his rifles, he was an avid hunter and fisherman. As time went on, he was diagnosed by his doctor with extreme GAD and was put on every anxiety med there is until he was able to find Ativan which made him only feel “normal” again…where his mind wasn’t running with so many life changes. He went to Pain Management for two years where they twisted and poked and prodded him as he screamed in sheer agony. His doctor finally put a stop order on all physical therapy; this young man just could not take it nor would it make him better. Pain management put him on MORPHINE! He couldn’t think, concentrate, make decisions; he hated it!! After his gastroenterologist took over his care for the damage done to his intestines, he tried every pain med available until Cephadyn finally helped without making him “out of it”, still he suffered pain. I believe that is balbubital with acetominaphen and caffeine or codeine, not sure. He was also on Soma for the nerve damage in his legs. He has a hernia, an enlarged prostate, a very enlarged colon filled with polyps, too many to remove without a cholostectemy (?). This is a FORTY-FIVE year old man whose doctor retired the day before my friends next appointment with him…he cut down all of his meds to 1/6 of his daily dosage in order to survive…barely. That was almost a year ago this August. I flew down to where he lives as he couldn’t get a new doctor without going through horrible anxiety. When the day came for the doctor’s appointment, she said she could not give him those meds because in January 2009, Medicaid changed the law that no person who had not been in the same doctor’s care for a minimum of two years could get any type of barbituate. Like it was his fault that his doctor retired due to health reasons without any notification beforehand. This man is in excruciating pain on a daily basis. It feels as if meat is being torn from his bones, he tells me. I got him an appointment with a new gastro due to his diahrrea which is instant after every meal. He has gone from a 6′ tall man weighing 180-185 to the same height weighing 125 lbs.!! And the government has tied his hands to live a somewhat pain-free life…even with meds, he will be in pain however not to this degree. He has talked a lot about dying, wanting to die. Two years ago, his brother killed himself after a divorce and his mother went down with Pick’s Disease and she was his sole support. He needed one more quarter to get more disability but he has to live on only $695/month!!!! When he went to the new gastro, the first thing the man said to my friend, when he walked in the door, was “if you’re here for pain pills, you can leave right now!” Can you imagine how my friend felt?! He was there for all of his problems…he taught himself how to walk after two years and then to drive, but he only has an old standard pick-up truck and when nerve damage in his legs are acting up, he can’t even push in the clutch…and this high and mighty doctor has the nerve to offend this sweet, dear man. I’m trying all I can to get drugs from another country without a script for him….yes, illegally…you think I care?? No, I only care about getting help from a doctor with brains and a heart to help this precious man….yes, I AM PISSED OFF BIG TIME!!! Thanks for letting me vent. Pain Management…yeah, right!!
THE CATHEDRAL OF DRUG AVOIDANCE -
A CASE STUDY IN CONVOLUTED REASONING
My previous post stated that, “The (rhetorical) ’shoes’ that patients suffering (acute, and especially, chronic) pain stand in are quite different from those worn by physicians …”
Several statements made by “LastoftheZucchiniFlowers” (hereafter LOTZF) unfortunately reflect what I believe are patently unreasonable opinions combined with a troublesome sense of an imagined superhuman superiority that exists all too widely in the medical profession – and one that has served to engender and promote the public perception of arrogance, entitlement, and indifference in its members towards the very patients who pay for their services.
Such attitudes do little to counter Thomas Szasz’s statement that, “The War on Drugs is a moral crusade wearing a medical mask.”, as they are socio-politically strategic, and are not grounded in known pharmacological facts surrounding opiate/opioid medications for analgesia.
LOTZF: “When in training and studying the mysterious phenomena we call ‘pain’ I recall being taught the following maxim: Pain is what the patient says it is. This predates the 1-10 scale but still holds promise for the provider to comprehend what the pt. is trying to say.”
DR: OK. That sounds like a reasonably humble thought.
LOTZF: “I maintain that the ED is NOT the place for those with chronic pain to secure medication.”
DR: So, LOTZF, who made you King (or Queen)? It’s nice that your “loved one” is prescribed 90-day supplies of oxycodone in the amount of 20mg per day in order to address their pain. You seem to approve in the case of your own personal relative …
LOTZF: “… He NEVER needs to visit the ER …”
DR: That’s nice (but entirely anecdotal).
LOTZF: “… because his chronic condition, like all other chronic conditions, is managed by a physician who knows him long term … ”
DR: Similarly anecdotal. Not necessarily at all the case for many members of society. What causes you to assume that the rest of the world functions in a model that you construct relating to one particular person’s situation?
LOTZF: “… and knows he is NOT a drug seeker …”
DR: I think that I can (almost) hear the organ-music …
LOTZF: “… but rather a patient suffering chronic pain who needs and thankfully recieves proper treatment from a caring, knowledgeable physician/surgeon.”
DR: Well, its great that your “loved one” has managed to make such arrangements. Why does the rest of the world deserve less understanding, compassion, and care from the medical profession in general (including in the ER)?
LOTZF: “… Going to the ER for chronic pain management is unwise and a poor use of ER services.”
DR: I would wager that you would not yourself be so full of judgment and certainty were you a similarly situated ER patient in pain yourself. Why would you treat other human beings differently than you yourself would (likely) desire to be treated? Ever imagined life in *their* shoes? … Ever?
LOTZF: “… these ‘breakthrough’ events should be discussed with and managed by your pain specialist so that WHEN the weekend comes and he is ‘not in his office’ and the worse case scenario occurs, you are covered.”
DR: That makes nice academic textbook material – assuming that the patient is a seer who divines the future – and who has a physician who buys in (rather than raises a jaundiced eyebrow) to such prophecies of future events. Sort sounds like “DRUG-SEEKER” talk, would not you (yourself) say? …
LOTZF: “… Patients have a responsibility to anticipate their needs, since we know ourselves best and to make preparations for our needs.”
DR: Now we are *really* pushing the envelope of dis-credibility. Sounds like a world-class projection of blame for patients not being seers. Do *you* divine the future, yourself, LOTZF? If so, I guess you would know what the patient will or will not need in future, as well …
LOTZF: “… The disposition and empathy of ED are a direct reflection of misuse of their workplace.”
DR: Presumably a justification for a high degree of suspicion, condescension, and despite toward the patient on the part of the medical profession. This is the classic pathology of the mindset: “blame the patient – and charge them a bundle anyway!”. Such gushing empathy gives a lot of credibility to statements such as, “It’s amazing, the self absorption here.” (-Paynehertz).
LOTZF: “… And do not misunderstand, I am in full agreement that people in pain must have their pain alleviated – just don’t expect the ER doc on duty to be your patient when you show up there with your saga.” …
DR: What? This is like saying that ER physicians are beholden to a different oath – simply because they work in a complicated and stressful environment. Totally bogus.
The idea that a client would expect the ER doc to be *their* patient is a strange convolution that is emblematic of the veracity of my previously posted statement – that the prospect of patients noting what does, and what does not, address their (subjectively perceived, and thus non-reducible) experiences of pain, and correspondingly communicating their experience and wishes to the physician, presents a troubling threat to the physician’s sense of primacy in decision-making. This is about power, privilege, and self-absorption within the medical profession – and *not* about the patients (ostensibly) served.
LOTZF: “… the ER doc is NOT your doctor …”
DR: A patently strategic “dodge” – plain and simple. If ER doctors are not physicians, what are they? Inquisitors and torturers? If so, why does the patient pay far in excess of the amounts charged by other physicians? For suspicion, condescension, and indifference? Please.
LOTZF (referring to a “regular” physician that the patient either may or may not even have): “… He/She will help you – trust me.”
DR: This is not only a “dodge”, but is also a far-stretch (considering the attitudinal tone of your statements in general). How could/would you know these things? Insurance adjusters use the same tactics – but, do we believe them? Why should we believe *you*?
LOTZF: “… My uncle (mentioned earlier) has HIS pain doc’s home # but in three years he has NEVER called him at home. He says something about just knowing that he CAN is relief enough.”
DR: That’s nice, but (again) entirely anecdotal. Do your standards for “proper patient behavior” when experiencing pain *all* arise out of your uncle’s personal situation and experiences? For the sake of society, I do hope not …
LOTZF: “… Nice thought and good luck to you in your search for freedom from pain. Whether it be physical and/or psychic pain matters not – both types will sap life’s joy leaving hopelessness in its wake.”
DR: Your “cruel compassion” strikes me as right out of a Franz Kafka novel. Ever considered a profession as a writer of fiction? It looks like you (already) have made a good start.
LOTZF: “… Whatever you do, DON’T take so much medication that you stop breathing. Sounds silly but it happened EVERY NIGHT across America …”
DR: Sagely advice indeed (the bit about not killing oneself via overdose due to respiratory depression). Since it is clearly the tabooed opiates/opioids that bring forth the greatest swells of organ music and choir – why not note that the “theraputic index” (Lethal Dose / Effective Dose) of these substances used alone is *very high*, and safer than many, many other medications (including NSAIDs and alcohol, that any adult can purchase in any amount)!
LOTZF: “… NO DECENT PHYSICIAN wants to be mixed up in the drug overdose death of a patient they don’t really KNOW! …”…
DR: Or (I presume), the death of patients that they *do* really know! I do not advocate putting loaded guns in the hands of suicidal fools. But I think that your rhetoric appears as more strategic in serving your own personal interests and net financial worth first, with the well-being of patients taking (at best) the last seat in the back of a (rhetorical) “bus” full of “bozos” (except, of course, you).
Your polemics may dove-tail nicely with the “flavor of the day” hysterics surrounding doctors within our society scrambling to cover their own bureaucratic derrieres, have a profitable career, and a very nice life, etc., but – the pharmacological facts surrounding opiate/opioid medications do not support your claims, and more and more competent adults in our society see through the sermons and extreme unctions so commonly proferred by yourself and other physicians within our profession as a justification for denying patients adequate relief from pain.
Instead, these human beings see through the moral pontifications, gesticulations, and professional strategery to the unfettered “me-ism” that commonly drives such doctrines of the avoidance of these relatively non-toxic medications in favor of (often more toxic, and, interestingly, significantly more profitable) treatment regimens. Just who, then, are the *real* charlatans here?
The “DRUG-SEEKERS”, or
the “DRUG-WITHOLDERS” …?
It’s becoming rather hard to tell in these darkening ages …
.
Doctor Rocktor,
I am not a doctor but have been a chronic pain survivor for 35 years. I will have to say you put into words much more graciously than I what needed to be said to” LOTZF “. I have had over 40 to 50 doctors between the Veterans Administration who I must say is nothing short of a first aid station touted as one of the most technologically advanced medical facilities in the country is all bogus BS just like the politicians pump out. I will have more to say on this mater later but have to take my wife to what I hope is an understanding doctor due to a tear close to her rotator cup.
But in the mean time Dr. Rocktor I can only hope that if I ever have to find a new doctor because this one goes Opiophobic on me I can find one as understanding as you see to be. God Bless
Russell
Though a bit baffled by the furore generated from a FEW by my comments on the ER being the WRONG place to obtain narcotics – I nevertheless stand by my words. Not only that, I’ll reiterate them a final time since perhaps I was not clear in my initial remarks (as they DID contain anecdotal commentary). This time I am speaking ONLY as a provider:
1- All patient pain should be alleviated.
2- All tools in our the therapeutic armamentarium should be brought to bear in this effort.
3-THE ER IS NOT THE PLACE to go to get REFILLS for your CHRONIC PAIN medicines.
4- My answer to ‘doctor’ rocktor – it is YOU, sir, who ought to have considered a career as a writer of fiction.
And now – back to the ER.
Russell,
Thanks for your kind words. I consider myself (first and foremost) a fellow human being, and (secondarily) a physician. The reason that I have some understanding for the shoes that chronic/acute sufferers of pain walk in has a lot to do with the fact that I myself have dealt with 28 years of chronic severe neck/head aches, have torn my left rotator cuff (4-6 months of excruciating pain) as well as my right rotator cuff (4-6 weeks of the same). In addition to any analgesia that (I pray) you folks may be fortunate enough to be allowed experience – make sure to (gently, but diligently) “keep moving” (exercise) such infirmities! The foregoing statement (in deference to all you “concerned professionals” out there) is “human” – and not “medical” – advice …
Being (roughly) your age, I have experienced decades of life as a stranger (being a civil libertarian and a fiscal socialist) in a strange land (of fiscal libertarianism and moral totalitarianism). Integrity is a hard term to define per se – however, we all can point to examples of its absence.
Make no mistake – it is important that folks who use opiates/opioids on a regular basis understand that they are a helpful adjunct to the essential practices of remaining active (in terms of regular exercise), as well as maintaining a healthy diet, in realizing and maintaining “wellness” where it comes to chronic pain conditions. There is no easy way to negotiate these waters, and no panacea in a pill that exempts one from these realities.
The problem (as I see it) is that out of the millions of sufferers of chronic pain conditions in our society, there are many competent adults who recognize and act upon the above mentioned realities – and are not imbeciles in need of constant paternalistic supervision by moral nannies (themselves often obsessed with maintaining a profitable “dependence” in its own right based upon relegating patients to a childlike status in order to sustain their own pre-eminence as “deciders” and “arbitrators” of human behavior).
I believe that the core problem surrounding opiate/opioid medications arises not out of pharmacological realities, but (instead) out of our society’s unique and misplaced obsessions with a judeo-christian “anti-pleasure” ethic that has arisen in last century (due to its privileged and entitled proponents in positions of social power, and their self-serving desired control over the minds of others), thus malignantly permeating and (falsely) distorting society’s discussions of what it means to be a citizen in a free and open society.
We (some, anyway) seem obsessed with (not only) owning the bodies of others, but also with the absurd and immoral premise of owning the *minds* of others. This is (in no uncertain terms) a “tyranny”, and (one finds) is always promulgated by those who stand to profit (whether by financial or moralistic means) from standing in the dubious role of paternalistic magistrate over the free will and choices of competent adults.
Your use of the term “opiophobic” indicates that you may be familiar with the thoughts of the person who coined that phrase (Thomas Szsasz, Professor Emeritus of Psychiatry, SUNY), who (also) sagely stated, “How can such paternalism on the part of the rulers lead to anything but infantilism on the part of the ruled?”.
Szasz (in his 1985 book entitled, “Ceremonial Chemistry: The Ritual Persecution of Drugs, Addicts, and Pushers”) draws a cogent and telling analogy between the age-old “theocratic state” and what he terms as the modern “theraputic state”. These parallels are as humorous as they are tragic – but do indeed spell-out what I have come to believe is the *real* story that drives today’s imbroglio:
Dominant Ideology: Religious/Christian = Scientific/Medical
Dominant Value: Grace = Health
Interpreters, justifiers, prescribers and proscribers of conduct and their ostensible aims:
Priests = Physicians
Clerics = Clinicians
Nuns = Nurses
Saving souls = Curing bodies and minds.
Heroes: Saints = Heroic healers
Heretics: Witches = Quacks
Ceremonies and Rituals:
Confession, penance = Psychotherapy
Holy Orders = MD degree.
Extreme Unction = Medical death certification.
Panaceas:
Faith = Scientific knowledge.
Hope = Scientific research.
Charity = Compulsory treatment.
Holy Water = Theraputic drugs.
Pana-pathogens:
Satan = Christian Scientists and others who defy the authority of medicine.
Blasphemy = Rejection of medical science and medical treatment.
Witch’s Brew = “Dangerous Drugs”.
Prohibited Items:
The Bible in the “vulgar” tongue = Drugs in the free market.
“Dangerous Books” = “Dangerous Drugs”.
Unprofessional Conduct:
Selling too many indulgences = Writing too many prescriptions for “dangerous drugs”.
Questioning the infallibility of the Mother Church = Questioning the infallibility of modern medicine.
Agency of Social Sanction:
The Inquisition = Institutional psychiatry.
Aim of Social Sanction:
Forced religious conversion = Forced psychiatric personality change.
Thus, the “great unwashed” stand trembling and helpless in the “Cathedral of Drug Avoidance”, praying that (self-declared) “Doctors of the Universe” will take pity on their humble souls as mere commoners, and dribble a few “communal biscuits” upon the “hoi polloi” in order to absolve them of their “sinful sufferings” for a few brief hours – until the pay-for-service “cathedral” opens once again for business in the morning.
In the Reformation, Martin Luther attacked the dominant Church of the day for just that – selling “indulgences” (charging monies in order to absolve them of their sins, and ensure their entry into “heaven”). This was, indeed, the practice and function of the (rhetorical) “Whore of Babylon” …
Feel free to draw your own parallels, but do not expect much more than outrage and despite from the “Church of Drug Avoidance” who decry that their service to the “King” (the almighty dollar, and/or their misplaced delusions of grandeur) exists for the sole (and sanctimonious) purpose of “saving you from yourself”.
For those who might ascribe to concepts of “original sin” (that humankind is, from the get-go, flawed and sinful, and in need of supervision from on-high) – consider that the “high priests” of the “cult of drug avoidance” are but *themselves* human (and perhaps in need of a bit of humbling from above, themselves).
Note: Don’t expect much more than (what they themselves term as) “a state of denial” from the “theraputic priesthood” should you confront “Simplicio” with the premise that the solar system does not, in fact, revolve around such mere humans as themselves. They broke Galileo’s spirit and imprisoned him for life for the high crime of using his head. In some respects (where it comes to the “cathedral of science” in the “age of reason”) little has really changed where it comes to human nature. The faces have changed, but the hymns remain the same …
Heretically Yours, DR …
.
LastoftheZucchiniFlowers,
Perhaps I misunderstood your other post also, I will agree that the ER is no place to get your refills for your pain medications with one exception. The DEA has gotten so gun ho on investigating and pulling the license of doctors because they may not have their paperwork exactly write or a few other horror stories I have heard and read about. If your doctor gets investigated and they take all his medical records you can’t get in to see a pain specialist in a couple of weeks my experience has been it will take you at least 30 days in the state I’m in, so in a case like that I make it a point to obtain copies of my medical records and keep them as up to date as possible. With this in hand and your proof of past prescriptions which the pharmacy will give you I think that is an emergency case because you could go into withdrawl and die from that. I hope some other patients are reading this and take heed it could happen to your doctor at any time. My doctor works in an office with 7 other doctors the DEA walked in not to long ago and named the doctor he wanted to check out and told his nurse to pull him 3 random files and bring them to him. She complied, his paper work was all in order and they passed that go around but doctors must require all that paperwork you have to fill out to cover their butt and their lively hood they have spent a lot of money and a lot of hours to get to where they are so try to see it from their side one slip and their license may get pulled and without a license a doctor is dead in the water. I thank God for those that do take the time to listen, keep their paper work straight, and ask me for any copies I may have that they need. It covers us all because I could not stand the excruciating pain levels I would experience without my meds this has happened to me twice before and I was admitted to the hospital because my blood pressure was so high they was afraid I was going to pop a valve. I salute all you doctors who truly try to help those who suffer with chronic intractable pain disease.
Russell
LastoftheZucchiniFlowers,
Thank YOU for clarifying what it was that you “must have” (originally) intended to mean. Perhaps (at times) we can all learn from the thoughts (however seemingly adverse) arising out of the humble minds other fellow human beings …
I leave you with the following (lightly embellished) adage (capitalized so that the whole world know that I am emphatically serious!):
“TRUTH (as often as not) “IS” (even) “STRANGER THAN FICTION”
.
I take tylenol with codeine one to three tablets daily due to chronic pain associated with a torn miniscus and diabetic neuropathy. Prior to that I had been on Vioxx which relieved the pain but we all know what happened to that. Other NSAIDS caused rectal bleeding. I use the tylenol with codeine carefully and only when needed. I makes the difference between being reasonably comfortable and being in much pain. Doctors should not be wary of prescribing opium related drugs WHEN NEEDED. But care should be taken to appropriately each case over time.
Comments on this entry are closed.