Opiate overuse and Michael Jackson: Time for the pendulum to swing back?

OpiateI was recently asked by a police officer why doctors prescribe so much opiate medication knowing full well that we are in the midst of an addiction crisis.  Many people are hooked on opiates; pills, patches and injections, and the problem is getting worse.  Anyone who works in the ER is aware of “drug seeking” patients who may not have a real medical problem, but repeatedly come into the ER seeking narcotics for various types of pain.  The police officer sincerely wanted to know why doctors are so willing to prescribe high doses of opiates when the costs of addiction are so high, and this question has recently been brought into the spotlight with the death of Michael Jackson.

It’s a difficult question to answer, but I feel there are several sources of pressure put upon physicians to provide these medications.  First, 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.

Additionally, physicians and hospitals are now obsessed with patient satisfaction.  We are monitored constantly, at the level of the hospital, the ER and individual physician.  When satisfaction goes up, physicians are rewarded, and when it goes down their very jobs may be at stake.  If a doctor takes a “hard line” with opiate seeking patients, satisfaction numbers will predictably plummet.  Not giving some patients the opiates that they want and expect will often times result in arguments, profanity, and calls and letters to administration.

Finally, pain is now considered by the medical establishment as the “new vital sign.”  When patients present to the ER, they are asked to rate their pain 1 through 10, and then this number is followed all the way through discharge or admission.  The implications with regard to opiate addicted patients can be profound.  If a person states they have a 10/10 pain on arrival and it has not decreased whatsoever at discharge, the physician appears to be at best complacent, at worst sadistic.

For the above reasons, I believe the medical establishment is helping to fuel the opiate crisis in the US, and it is time to re-evaluate our expectations and our processes.

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Better Health » Physicians Under Pressure To Prescribe Narcotics
07.29.09 at 9:01 am

{ 8 comments… read them below or add one }

girlvet 07.14.09 at 8:45 am

It is reasoning like this that has led us to become a nation of addicts. Any doctor who prescribes narcs because of patient satisfaction survey numbers will go down or because of fear about pain scale numbers is pathetic and should exit the profession.

Nurse K 07.15.09 at 8:37 am

Do you REALLY think the average drug addict takes time to fill out the survey? Probably not. If you give narcotics when there is a reasonable belief that the patient is going to sell or abuse the drugs, you’re prescribing illegally, right? If they show up 8 times in 8 days (I had a patient do that the other day) with various painful complaints w/ a history of polysubstance abuse and you prescribe narcotics, isn’t that ILLEGAL? I’ve had patients with track marks and bogus subjective pain complaints (eg. “hand pain for a year”) get prescribed narcotics. ILLEGAL.

MB 07.20.09 at 6:38 am

TO: “girlvet”

Trust me, it’s not the doctors, its the admin pulling the “strings”. It’s like the admin is prescribing by proxy.

MB 07.20.09 at 6:42 am

TO: NurseK,

Remember sometimes it’s hard to decide what these people’s “needs”. Sometimes the repeat pt who comes back the next day, may in fact, really not have had his pain needs met. He could be TOLERANT to higher doses and require higher doses even for a legitimate/acute problem; and because they’re TOLERANT (not Addicted, and not Abusing) they will ask for higher doses/more Rx’s, even for their acute problems.

Remember there are FOUR categories:
1) Tolerance
2) Dependance
3) Addiction
4) Abuse

Not all FOUR are illegal, nor does it negate the provider having to weed though the problem and see what the pt’s issues are. As the original blogpost said, it’s “difficult” many times to sort out and determine who “really” needs their pain addressed.

It’s hard.

tamoroso 07.28.09 at 8:30 am

@Nurse K: you betcha the patients/addicts fill them out, if they receive them. And believe me that some (not all-my current boss is fairly good in this regard) chiefs of service will call you into their office and read you the riot act for failing to give this person who has filled out a negative survey narcotics. because the chief’s pay hangs in the balance (as, often, does the doc’s).

“Satisfaction”, like return rate and complication rate, is a crude measure of how good a physician is at his or her job. And it is vital to document document document any suspicion of drug-seeking. Do it every time, on every visit, because I/we may not read back more than one or two visits (I don’t have time to read every chart the patient has generated, especially if they’ve come 8 times in 8 days). If I can point to the suspicion of drug-seeking in the chart, that is an active defense against the patient’s complaint. In addition, the creation of regional (or even national) prescribing databases (so providers can see every scrip you’ve ever filled, anywhere in the region/US) would go far towards curbing this epidemic. Sadly, the fear of “Big Brother” is greater than the fear of drug-addiction, apparently.

Docktor Rocktor 07.29.09 at 6:12 am

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.

Erin 08.29.09 at 4:56 pm

It is always such a fine line to draw because each and every situation is different. Its one of the reasons I respect those in the medical profession, because only those certain few people will really be able to assess those situations independently of one another.

tb 10.29.09 at 9:40 am

ER Doc You are soooooo missed. Please come back!!! :(

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