I have a lot of ER stories that involve drug addiction and drug seeking behavior. I knew a patient who intentionally dislocated his shoulder three times in one day to receive pain medication. Another had a friend who stole an entire dirty needle box in order to rummage through it for injectable drugs.
I have been told by patients that pain pills were eaten by dogs, stolen by neighbors, lost in car crashes, accidentally flushed down toilets and all the rest. People have pleaded with me because their normal doctor was out of the country. One individual (call him Bob) came to me and was denied narcotics, then returned two hours later with a woman’s ID and saying he was she (call her Carol).
“You aren’t Carol, I just saw you.”
“Yes I am, I’m Carol and I’m in pain.”
“Get out,” says I.
The list goes on and on and every physician has a few of his or her favorites.
In the annals of American medicine, it turns out this was all rather new territory, at least in scope. My career began in the early 1990s when there were (for various reasons, corporate and otherwise) powerful initiatives encouraging us to treat pain with more narcotic pain medications such as Lortab, Vicodin, Percocet and others. We were regularly scolded for being cruel and insensitive about people’s pain when we, young and innocent as we were, expressed discomfort with this practice. I remember being explicitly told, more than once, “You can’t create an addict in the ER.”
We were told that pain was the “fifth vital sign” and were taught to use a “pain scale,” which you’ll hear to this day whenever you interact with the health care system. “What’s your pain on a scale of zero to ten with zero being no pain and ten the worst pain of your life.” Most nurses can say this in their sleep. We developed smiley face scales for small children to use.
We learned to give narcotics regularly for various types of pain, when they had been previously reserved for cancer, long bone fractures or significant surgeries. Medical boards were encouraged to discipline doctors who were reported to under-treat pain. And hospital administrators, ever in love with the “customer satisfaction” model, pressured physicians whose patients complained about receiving inadequate pain treatment. (High patient satisfaction scores have been studied and associated with poor outcomes, by the way.)
Although it’s difficult to quantify because physicians feared for their jobs, I’ve spoken to many physicians over the course of my medical and writing career who were told by their employers to give narcotics when requested or risk loss of income or of employment.
This happened even in the face of staff who knew the abusers. We used to keep files so that even new physicians could tell who the problem patients were. Eventually, we were told to stop. It was a kind of profiling and it was unacceptable. Always assume they’re telling the truth, we were told.
Sow the wind, reap the whirlwind. Since 1999, prescription narcotic overdoses soared, quadrupling over the period to 2014 according to the CDC. Over that period, there were 165,000 deaths from prescription opioids, most commonly hydrocodone, oxycodone, and methadone. In 2014, more than 14,000 people died from those drugs.
Now, the move is from condemning our insensitivity to questioning our judgment. Prescription drug abuse is a high priority for state and federal law enforcement, state medical boards, the Drug Enforcement Agency and the Centers for Disease Control and Prevention (which recently released new, more conservative guidelines for chronic pain treatment).
States are using online prescription monitoring programs and many hospitals are putting policies in place to give as few narcotics as possible in emergency departments. It’s a Catch-22 of course, as some patients with legitimate pain are told to find pain specialists or family doctors, when they either have no money to do so or have no physicians in the area taking patients. Thus, they circle back to the ER where we try our best to remain both diligent and sympathetic.
Physicians and hospitals are now engaged in a constant battle to combat drug abuse, to save lives and help empower the families of those struggling with addiction who are desperate to help their sons, daughters, husbands and wives.
I hope we maintain our compassion. But I also hope that it keeps getting harder to walk into an office or ER and get addictive, lethal prescriptions.
Because it’s time for this nightmare to stop.
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