I’m addicted to prescribing pain medications

Hi. I’m a 44-year old emergency physician. And I’m an addict.

My addiction came to light when my Press Ganey scores plummeted after I started to stand up to the chronic pain and frequent ER patients.

The fact that I have an addiction was reaffirmed when I went to my state’s Prescription Drug Abuse Summit. When I saw so many professionals from varying fields (medicine, law enforcement, pharmacy, education) assembled, I realized my problem: I’m addicted to prescribing pain medications.

As with any addiction, the first step in treatment requires acknowledgement of the problem.

I thought back to how my addiction began.

Coming out of medical school, there is a certain power that comes on the first day of residency. You suddenly have the power of the pen. You can write prescriptions for low blood pressure, high blood pressure, low blood sugar, high blood sugar, too many bowel movements, not enough bowel movements.  The list goes on and on. But one of the largest ways in which we can help patients is by treating their pain. Controlled substances. Yes, the new physician quickly learns that the pen wields an awesome power and an awesome responsibility. This feeling fades quickly in the face of an 80+ hour work week.

Fast forward 5-10 years. You are seeing 10-12 patients at the same time, all the chest trauma goes across town, and you have a waiting room that is 20 patients deep, and you already know the medical history of ten patients waiting to be seen on the tracking board.

Hospital administrators pressure you to make sure that all non-emergent patients are treated and released within 90 minutes. All admits must be up to the floors within 240 minutes, if only the medicine consultant would get down and actually see the patient.
It’s not uncommon to see 40 or more patients in a shift. I make it a point to look up the prescription/controlled substance database our state has. This has been an absolute lifesaver to me and to several patients I have confronted.

The problem is that it takes time:

  • 2 minutes to look up the patient and print off the list
  • another minute to count up the number of prescriptions (it does take time to count to 50 or even 72 – my personal best record for one year)
  • another 3-5 minutes to go to the room and confront a patient who has an issue
  • then a few more minutes to sit down and document the conversation.

So I have 10 minutes to evaluate a patient, create notes in an arcane electronic medical record, and discharge the patient. Yet all of that time can be taken up by doing what is right with drug seeking patients. I cherish the ability to “catch” someone who is diverting drugs, to be able to sit down with them and have that “aha” moment. I have even had a few patients come back and thank me for confronting them. But my worth is partially measured by the number of patients I see per hour. My worth is also partially measured by my patient satisfaction scores. It’s not all possible.

Why do I and so many other physicians have this addiction? Not providing the prescription is very hard. It takes time to do the research on the patient. Confronting the patient with a problem is emotionally draining. Doing it 5-10 times in one shift is not only a reality, it is downright crippling. It sucks out last bit of energy out of your soul. Rather than confronting patients and arguing, it’s far easier to write a prescription for narcotics and move on to the next patient. This is the mindset of thousands of physicians. Healthcare is different than it was 5-10 years ago.

As soon as I started saying “no” to drug-seeking patients, it was as if I had been liberated. I still have lapses and give out prescriptions to a patient against my better judgement. And I occasionally get burned. I am human and some days I just don’t have the energy to argue and fight with drug seeking patients. As time passes, however, saying “no” gets easier.

Physicians need to start saying “no” once in a while. Take the time to review a patient’s medication history. Don’t be the doctor who prescribes the patient’s 300th Norco tablet of the week. Saying “no” just once a day can be liberating. Try it just once a day for a month. Then twice a day. It gets easier. At first, I actually felt guilty when I wrote for Ultram instead of Vicodin. It has become easier with time.

Physicians can’t fight this addiction alone, though. We need the backing of hospital administrators. Hospital administrators must listen to physicians and see how much of a toll the prescription drug abuse epidemic is taking on patients, the healthcare system, physicians, and the bottom line. How many $500 ER visits will a hospital be willing to write off when they learn the patient just wants 20 Vicodin? Hospitals must stand behind and support physicians who are willing to stand up to drug-seeking patients. Perhaps patient satisfaction scores will take a hit. So be it. Administrators need to take a step back and see the big picture on this one.

Maybe administrators need to be held legally liable for patient overdose deaths when they haven’t created a policy for dealing with medication prescriptions. Sometimes getting sued is the only thing that makes administrators wake up.

So, I’m out of the closet. I am a recovering “controlled substance prescribing addict.”

It feels good to be free of that burden.

Most of the time at least.

This anonymous physician blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly and Dr. Whitecoat.

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  • http://www.facebook.com/johnckeymd John Key

    It’s not just the administrator–though I admit I was once “ordered” by a VA Center Director to double a patient’s Vicodin prescription from 240 to 480 pills for one month. Other factors are the challenge of correctly evaluating what the pain needs of the patient really are; the appropriateness of the pharmaceutical to be used, the availability of other modalities to use, and the ultimate prognosis.

    Other less savory and high sounding factors include physical fear of the patient, financial fear of losing the client, the reluctance to “run off” a patient when their fee can help keep your doors open for another week.

    It was a problem for me, that classic “double-bind situation”. Now I work in a correctional facility where the controlled substances prescribing dilemma is but a distant memory.

    It is liberating indeed.

    • ninguem

      What in blazes is any patient doing with 480 Vicodin a month?

      That’s 16 pills daily. Daily Tylenol 5200 to 8000 mg daily, depending on the 325 or 500 mg Vicodin.

      The patient is heading to liver failure.

      • azmd

        Selling it on the street, most likely.

        • ninguem

          Well…..yeah.

        • Payne Hertz

          Of course. What else could someone possibly use pain medication for? These drugs are only given by bad doctors to bad patients so they can kill themselves and every high school student they can sell their drugs to.

          What a planet.

          • Theresa Bubenzer

            If someone has chronic pain, then the ED is the worst place to deal with it. Hystericall outbursts to the contrary, there are other means of dealing with pain which however necessitate the patient take some responsibility. What a novel idea.

          • Payne Hertz

            Wherever cruelty, ignorance and bigotry rear their ugly heads, the “personal responsibility–what a concept” meme is sure to follow.

            There are 100 million people with chronic pain in the US and the other 230 million will also suffer acute pain at some point in their lives. But all these people are lacking in personal responsibility, except for rich people and quack-therapy peddlers who always blame patients for the failure of their treatments.

      • Harry

        “Daily Tylenol 5200 to 8000 mg daily”

        Well, patients who dare to seek pain relief DESERVE to have their livers destroyed, AMIRITE???

    • Payne Hertz

      A VA administrator cannot order you to prescribe drugs to a patient. The dose you prescribed vastly exceeded the maximum daily dose of acetaminophen while not being a particularly high dose of hydrocodone.

      The only person responsible for breaching the standard of care is you. Your patient did nothing wrong but request treatment.

    • Harry

      Your patient was desperate for relief from pain, so you’re going to punish him by gratuitously and unnecessarily destroying his liver. Nice. That’ll show him!!

  • Payne Hertz

    Looks to me like you’re addicted to the sadistic rush of power you get from abusing and denying treatment to suffering and desperate people for the “crime” of having chronic pain and seeking treatment for it. Seems like you’re having a lot of fun destroying people’s lives.

    But that’s okay. There is a witch hunt against American citizens with chronic pain and you can justify it the way every witch hunt throughout history has been justified: by claiming you are doing your victims a favor. Inquisitors who burned heretics at the stake figured they were saving their victims from eternal hellfire. I wonder if they “cherished” the opportunity to burn someone?

    Providing opiate drugs to people who don’t need them simply because it’s convenient to you is malpractice, fraud, and felony distribution of narcotics. Refusing to treat people who have pain while taking their money is malpractice and theft. Abusing patients for kicks is the mark of a sociopath. The lack of respect for law, ethics and common standards of decency in this article speaks for itself.

    If anyone needs to stand up to abuse, it is people with chronic pain. As it is now we can be frivolously denied access to pain relief—a de facto sentence of torture— without a judge, jury or trial, and without any legal or constitutional protection whatsoever as well as no right to appeal our sentence. To say we live under the constraints of a ruthless, totalitarian system is putting it mildy.

    • PoliticallyIncorrectMD

      Here we go again… Drug seekers are misundestood heroes and doctors are there to hurt people. Brilliant analysis.

      • Payne Hertz

        The message of this article is that people with chronic pain are drug-seeking scumbags and doctors who torture and humiliate them for kicks are misunderstood heroes.

        Fixed that for you.

        • PoliticallyIncorrectMD

          Patients with chronic pain are not scumbags. I do, however, despise those who use chronic pain to demand opioids (proven to be the worst agents i.e the least effective and the most dangerous) for chronic pain. And I am proud of physicians standing up for what is right as opposed to what is easy.

          Also, do you really believe in”doctors’ conspiracy”? Do you honestly think that thousands of physicians go through years of training just to be able to experience the “sadistic rush of power [...] from abusing and denying treatment to suffering and desperate people”?

          • Payne Hertz

            As you’ve just aptly demonstrated, the ability of doctors to distinguish drug addicts from legitimate pain patients is zero. To you, any patient requesting opiates is a drug addict and worthy of contempt. This is what I mean when i say that seeking relief for pain is considered a crime by many doctors. Thanks for proving my point.

            Opiates are the safest and most effective treatment for pain when taken as directed, bar none. Your view is precisely the opposite of the scientific consensus. Thanks for proving my point that as in any other witch hunt, facts are distorted or invented to rationalize the brutality.

            Denying people pain treatment is not “what’s right,” it is morally depraved behavior. The doctor in this case freely admitted he enjoyed abusing and humiliating those he perceived to be drug seekers, and “standing up” to people with pain. At the same time he admitted giving these drugs to people who didn’t need them for no other reason than to shut them up and to game his Press Ganey scores, which is also immoral, depraved behavior.

            What is best for the patient and “do no harm” clearly doesn’t enter into the equation here.

          • Theresa Bubenzer

            Opiates are not the most effective pain treatment, bar none. Actually, CAM methods work much better–acupuncture, hypnosis, CBT. These are much more cost effective as well. The problem being there is no way to prescribe them in ED, or sell them on the street. The entire method of treating chronic pain in the ED is wrong and patients know that. If they are being seen at a pain management center, then they are violating their contract by seeking medication elsewhere. The ED doc is caught in the middle and no good is really served by this system except adding to the cost of an ED visit and probably getting more prescription pain meds on the street.

          • Payne Hertz

            There is no other place people with pain can realistically get timely relief from pain other than an ER, unless they borrow drugs from friends or buy them off the street.

            This stupidity is the fault of the system, not patients. Doctors and hospitals profit handsomely from this system when patients are forced to go to them and pay outrageous fees just to get 10 Vicodin. But somehow, the patients are to blame for using the only real option open to many fo them.

          • Theresa Bubenzer

            You have an axe to grind, Payne. There are many better ways to get chronic pain relief and going to ER for 10 Vicodans is surely not one. But, you know that. This is just a way to vent your pent up rage. I hope it helps.

          • militarymedical

            You totally disregard what Anonymous took great pains to describe: researching the state database for prescription patterns and history. That goes a long way towards differentiating opioid abusers from those with chronic pain. Too bad that you, like those myopic administrators, can’t see its value.

            Try looking beyond your own situation to the larger picture. Administrators and politicians (i.e., Bloomberg) LOVE to play practitioner and legislate medical practice. The result? Regulations and protocols that are skewed against those with legitimate needs because of the illegal needs of abusers.

          • Payne Hertz

            What you and your fellow authoritarians are unable to see is that controlled substances databases do not prove a damn thing. A person may be seeking drugs due to unrelieved pain, not to get a fix. Precisely how many doctors do you have to see before you are officially a “drug-seeker” and why is this stigma a life sentence?

            These databases punish patients who are unable to get adequate relief for their pain due to the cruelty and barbarism of this system. The insanity here is obvious. If patients were treated appropriately by the first doctor they see they wouldn’t have to run around getting scammed by amoral doctors who either don’t treat pain or do so with ridiculous amounts like 10 Vicodin to last a month.

            How would you like to be subjected to an arbitrary sentence of torture for a day, a week, a month or maybe years simply because you met the arbitrary criteria for “drug-seeking” established by some sadistic doctor who “cherishes” the opportunity to deny treatment to people like you based on worthless evidence?

          • militarymedical

            Listen, Payne Hertz (cute) – I’ve been “military medical” from 1966-2012, most of it in trauma/ICU environments, but the last four years were spent with Wounded Warriors – many of whom DEFINE the concept of “chronic pain.” This is not a new issue for me as a provider or for them as patients.

            “Arbitrary criteria” for protocols of any type are not established by some “sadistic doctor” – or any one doctor, in fact. I’ve come to be fairly decent at distinguishing drug-seeking behavior based on drug abuse from drug-seeking behavior based on chronic pain from a variety of origins. I have no qualms about clamping the lid down hard on the former, but would – and have – gone far out of my way to find relief for the latter.

            Chronic pain does not necessarily mean either a missed diagnosis or inadequate, poor treatment from the first doctor to see that patient. One example: some spinal conditions may face both doctor and patient with this choice – treatment resulting in the ability to walk, but with chronic pain, or less invasive treatment resulting in being wheelchair-bound but without chronic pain.

            You’re so smart: you choose between those alternatives.

          • Payne Hertz

            I’m sure you think you’re good at distinguishing drug addicts from “legitimate” pain patients; every doctor thinks he’s an expert at this, and never gets it wrong. But if you ask patients, the picture you get is quite the reverse, with the majority reporting being falsely accused of drug-seeking, in many cases multiple times.

            First, statistics are not on your side. There are over 100 million people with chronic pain in the US. and almost all the rest will experience acute or chronic pain at sometime in their lives. That is 1 out of 3 Americans right now and the entire country at some point in their lives. Are they all drug addicts?

            Statistics on opiate addiction show less than .6 of 1 percent of Americans have an opiate addiction. These low numbers are consistent across nearly every country, where there are few countries with a rate of addiction above 1 percent. That’s one out of every 166 Americans. So the overhwhelming majority of people who report having pain simply cannot be drug addicts no matter how much some desire to twist the facts.

            What always strikes me reading what doctors write about drug-seekers, is that they are always 100 percent confident in their abilities to detect them. They never have any doubts. Contrast this with Blackstone’s Formulation, where he stated that “It is better that ten guilty persons escape than that one innocent suffer.” What Blackstone was saying is that it is impossible to determine guilt with 100 percent accuracy, therefore it is better to err on the side of not harming the innocent.

            It seems that many doctors prefer to see 10 chronic pain patients suffer from their medical problem rather than let one drug addict escape the suffering of his medical problem. They never seem to be concerned with the certainty, let alone the moral consequences, of guessing wrong. Hell, they are not concerned with the moral consequences of guessing right and accurately stigmatizing a drug addict.

            Guess wrong and you may be destroying the medical care and the life of a legitimate pain patient, many of whom will commit suicide or turn to dangerous alternatives in an attempt to escape their pain. Guess right, and you will be subjecting a drug-addict to a night of cold-turkey opiate withdrawal, and he too may eventually commit suicide or turn to dangerous alternatives to escape his pain. In either case, you are not doing your patients any favors. You are harming them.

            Yet you “have no qualms about clamping the lid down hard” on those you perceive to be addicts. In 46 years of medicine, it never occurred to you to consider, even for a minute, what happens when you get it wrong? You know, like Blackstone did? Because I doubt that any ethical person who did consider the consequences could possibly agree to play drug cop, jury, judge and executioner as enthusiastically as the American medical profession does.

            The consequences of guessing wrong and guessing right are both so severe I could never play that game with human lives even if my own life depended on it. So you’ll forgive me if I have some issues with medical professionals who are willing to play Russian Roulette with their patients’ lives.

          • militarymedical

            We clearly agree to disagree. What you perceive as arrogance on the part of those of us who have responded to you in a way that is not in alignment with your views is greatly overshadowed by your own self-righteousness. Providers of all sorts make mistakes from time to time – including in assessment of pain – but that is due far more to human frailty than to your conspiracy theories.

            You can have the last word if you want. I won’t change your world view and you most certainly have not tempted me in the slightest to change mine, or even question it seriously. I’ve heard all your arguments presented here to date before.

          • Payne Hertz

            Your profession thinks hundreds of millions of Americans with pain are faking it to get SSDI and to score drugs and I’m the one with a conspiracy theory.

            I’ve seen your response a hundred times before so believe me when I say, I am not trying to convince you or any other doctor of anything. That’s a lost cause if ever there was one. I write for other people in pain, to expose this system for what it is, and to work for one which treats us as human beings and respects our freedom.

            Personal autonomy…what a concept.

          • Theresa Bubenzer

            Please cite research that shows opiates are “the safest and most effective treatment for pain when taken, bar none.” Actually, not the case.

    • Theresa Bubenzer

      There isn’t a drug corridor of trafficing in oxycontins “Hillbilly Heroin”
      because doctors were denying people pain medication. Nope. That traffic is created by the demand of people who say they have chronic pain. Perhaps they do, but it appears to be more psychgenic than physical and more of an addiction than anything else. Oh, and a way to make money. Times are hard and people don’t run moonshine anymore. They run oxycontins.

    • disqus_XpaeflETHK

      Thanks doc for practicing good medicine and not being intimidated by patient satisfication scores or the chronic pain drug seekers. These guys are classic in the chronic pain drug industry, generally either on soc sec disability for back pain or with a side business that promotes pain pill use. We already prescribe more Narcs than the rest of the world combined but it still is not enough for some.

    • adh1729

      Chronic pain is bad. Chronic pain + opioid addiction is worse. Be careful what you wish for.

      • Payne Hertz

        Addiction is bad. Dying from a destroyed liver, GI bleed or kidney failure due to NSAIDs, anti-convulsants and other “safe and effective” alternatives to opiates is worse. Opiates when taken as directed do not cause organic damage and are unlikely to kill you. Those drugs, when taken as directed, can kill you.

        • adh1729

          I am a general surgeon. I have watched my patients become addicted to opioids numerous times. They all told me that they were hurting, and needed them. They would badger me for refill after refill. I tended to give in to the ones who had complications from surgery. Then I ultimately had to detox them (no psychiatrist was willing.) I spent 5 years in that opioid/benzo/booze-loving community, and that was all that I could take, and relocated. Those types of patients were horrible. I had an appendectomy myself while there, and postop I took nothing. 10% of my patients would try to suck Dilaudid 48 hours postop as an inpatient after a simple lap chole. I agree that they needed something, but opioids were not the answer. Maybe they needed magnesium, or no MSG/aspartame. Not boatloads of opioids.

        • adh1729

          I agree that NSAIDS and other meds can have serious side effects. I had an injury several years back that kept me from sleeping for 2 weeks; I used a lidoderm patch, topical heat, and went to physical therapy. I did not use opioids at all. I feared them and I wish more patients feared them also.

    • tdmcdonald@triad.rr.com

      I completely agree with you! If these doctors had to deal with chronic pain on a daily basis they would understand what it is like. A never-ending pain, always there to remind you that you are its hostage and it will never leave you. I sometimes think that suicide
      is better than living in hell, but for some reason I hang on to life hoping that someday medical science will find a real cure for chronic pain sufferers. Then I realize that pharmaceutical companies really do not want to find a cure, because then they
      would lose that monthly customer and all that money. Who will help us? Who will be our advocate? Who?

    • disqus_XpaeflETHK

      Payne, are u worried about losing that disability check for your “chronic pain”, chronic fatigue, “fibromyalgia”, or that bulging disc? I am so sick of you entitled pain guys. Takers and scammers like you are going to bankrupt the social sec system for the rest of us. I commend the ER doctor.

      • Kay Dee

        I’m not defending Mr. Hurtz, but let’s not start with the conditions in quotes. Many, many people with “fibromyalgia” work full time jobs, take care of families, and deal with other chronic illnesses in addition to the one you apparently think isn’t real. I also commend the ER doc – drug seeking folks that clog up the ER system (or even my doctors office, or the line at the pharmacy) leave a nasty residue for those of us who follow.

        • Payne Hertz

          Narcotic addicts are .6 of 1 percent of the population. Not all of them go to doctors for their drugs, since few doctors will prescribe a dose high enough to satisfy a true drug addict.

          So those people you imagine clogging up the ERs and the line at the pharmacy scarcely exist to any significant degree.
          Putting “fibromyalgia” in scare quotes derives from the same bigoted, anti-patient mindset that stereotypes us all as drug addicts, whiners, “entitled” and all the rest.

          People who think like this are morally insane.

  • Patient isn’t always right

    Thanks! I’m a pharmacist and I get these folks when you can’t say no. To all of those who are worried about chronic pain patients, I will say that true, chronic pain patients plan ahead, have a relationship with a pain doctor and don’t abuse the emergency rooms in hopes of finding someone who will give in. This is not a refusal to treat pain, it’s a refusal to contribute to a problem that kills. Opiates in opiate novices kill. Increasing doses in opiate users kill too. This isn’t a witch hunt, it’s a disaster from the administration who wants everyone to be happy to the counters of minutae who count # of patients seen or # of Rx filled or worse yet – - wait times!! I applaud your efforts to try to help. Please allow the folks who are complaining in these comments to walk beside you, just a mile in your moccasins, ask them to pay your liability insurance, or mine. Health care is an awesome burden. Patients don’t say thank you, but you know, driving home that you saved a life today – - sometimes from providing life saving medicine and sometimes by denying the life taking ones.

  • Suzi Q 38

    Everyone feels pain differently.
    As for me I was prescribed Norco or Vicodin after every surgery.
    I really don’t need 60 vicodin. I think 30 after a surgery is fine.
    It just depends, I guess on what the surgery is. I also think that more time needs to be spent on helping the patient titrate the dose of a drug like Norco down. The nurse or NP can do this. After day 5 post op, ask them to start taking it only at night, and then use the regular Tylenol during the day. Then I started using the Vicodin or Norco every other night, until I had weaned myself off of it.
    Yes, there were some fretful and painful times that I had to “give in,” but that was rare. I started also cutting the tablets in half.

    I still have TWO bottles left of at least 30-40 in each bottle.
    What am I saving them for??? Who knows.

    I only use Aspirin, Tylenol and Advil now.