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Old 02-23-2011, 03:04   #18
Doczilla
Guerrilla
 
Join Date: Nov 2006
Location: Ohio, West Virginia
Posts: 137
Funny enough, I just had this email reply from one of our senior partners regarding drug seekers. Our group admin had sent out an email about a patient I had seen and refused narcotics after seeing an OARRS report showing multiple scripts for vicodin and percocet 2-3 days apart from multiple providers. She complained to the hospital CEO about me not giving her narcotics and suggesting that she may have an addiction problem, and threatened to picket the hospital until I am fired. The hospital and group are very supportive of me and of the care that she received. But this email went out from one of the senior partners in relation to a discussion of the Press Ganey surveys sent to such patients.

Quote:
The only reason Press Ganey comes into play concerns how we refuse the patient the narcotic prescription. I have a concern that some physicians are using the OARRS report to play "got ya" with the patient. Regardless, of your philosophy about giving narcotics, one should always treat the patient with respect, respect the HIPPA limitations and not embarrass the patient. I never tell a patient that I think they are addicted or a drug abuser. Those terms are derogatory. What I say is that as a medical doctor, I cannot ethically write for those medications out of concern that the patient appears to be using this class of drugs above and beyond their recommended dosage. There are always diplomatic ways to say things that don't trigger servere emotional reactions from the patient and the family. Also-our job as physicians is to treat patients and relieve human suffering-not to judge them. I tell young residents when they make social comments about a patient's lifestyle that if they want to judge, they should go to law school and seek a position on the bench.
Something about his email just got my dander up.

And my reply:
Quote:
Quote:
I have a concern that some physicians are using the OARRS
report to play "got ya" with the patient.
I'm not sure what this statement means. This is not a game. Prescription drug abuse is a very real threat to the lives and health of our patients. Since 2007, more patients die in Ohio from unintentional drug overdose than die in motor vehicle crashes or from suicide or homicide, and is the leading cause of injury death. 111 children age 15-19 died of drug/medication related poisonings between 199 and 2005. Drug related poisoning deaths have increased 300% since 2007, largely driven by prescription drug overdose. We have a responsibility to the patient to do what we can to prevent this.

I don't think anyone calls the patient names or talks down to them. It is our responsibility as physicians to recognize disease in a patient and counsel them to change behavior and offer help when we can. If your patient is noncompliant with their diabetes medication regimen, you would counsel them about it, wouldn't you? We would not belittle them either, call them names or use derogatory language. If they were engaging in any high risk behavior, such as drinking and driving, riding a bicycle without a helmet, or driving without a seat belt, would you not talk about this with them?

Everyone wants to make a patient happy, but we have to remember that we are expert consultants, hired by the patient, to render a medical diagnosis and treatment, not just give them what they want. We would also not give a treatment that was potentially dangerous and medically inappropriate. If a patient came in with nausea and asked you to take out their appendix, would you do it just to make them happy? Or if they were to insist on antibiotics for what is clearly a viral cold?

Opiates that we prescribe as emergency physicians are a short term solution for acute pain. Vicodin and Percocet are not appropriate as intermittent, uncoordinated, episodic treatment of chronic pain. Our accessibility in the ED leads many patients to turn to us for the "quick fix" for a problem that needs to be managed by a primary care physician or pain specialist. The patient may see the ED as an easy quick solution that requires no effort on their part. The effort of finding a PCP, making an appointment (well in advance, if the patient is uninsured), keeping the appointment, and following up appropriately, is often seen as burdensome. But care in the ED is not an appropriate or medically sound method of management for chronic pain issues. The patient must be told this, and followup encouraged, and sometimes that means not prescribing more opiates, which may only encourage the less appropriate management on the patient's part.

Some patients don't want to hear "no" when they ask for narcotics. Some of it is disappointment, but some, and I think the case below is an example, touch a nerve. They do not want to look in the face of a problem, and they displace that anger upon us. Alcoholics exhibit similar behavior when confronted about it by family members. This takes up more time on the front end in talking with the patient. It would certainly be easier and more efficient (during that one shift) to simply hand over a prescription. But in the long term, it increases our patient load in a system that is already stretched.

When a patient presents to multiple providers with the intent of getting narcotics, this is a crime, and not a faceless one. We can leave aside the cost to the group, the hospital, and the taxpayers in dealing with these patients. We can leave aside the 1500 patients per year dying in Ohio of unintentional drug overdose, 37% of which are prescription opiods and 75% of which identify multiple substances. Every one of these patients is taking up a bed, preventing us from treating other patients who are in the waiting room. This prolongs the suffering of our other patients, to whom we also have a responsibility. Coming in to the ER to illicitly or deceptively obtain narcotics is not a one time event. It is a pattern of multiple emergency department visits, taking up hours of physician and nursing time that could be spent treating patients with serious acute injury or illness.

Sometimes the way to an epiphany is a referral to law enforcement, and this is part of the reason for the HIPAA exclusion for those committing a crime on your campus. Intervention by law enforcement is a gateway to treatment that may not otherwise be available to the patient. Doctor shopping almost never results in a jail sentence, but will open doors to state treatment and monitoring programs that even we do not have access to. Contrast that with the opiod user that comes to the ER for "detox". Unless they are well insured, it is extremely unlikely that we will be able to arrange inpatient treatment.

When you recognize a pattern of inappropriate prescription drug use, ie., getting multiple prescriptions from multiple different providers at doses that exceed that which are medically indicated or advisable, then this should open a discussion with the patient. The patient may be using these narcotics to self-treat other problems such as depression, anxiety, or to retreat from issues at home such as domestic violence. These are all issues that I CAN help with, through referral to social services or psychiatry. The pattern of high risk behavior may be the event that brings the patient to me to open that door to help them.

To take into account the example that started this thread, I very nicely expressed my concerns over her multiple prescriptions. I talked about the possibility of tylenol toxicity, as well as non-narcotic methods of pain control. I kindly told her that I believed a referral to pain management was necessary to prevent complications from overuse of these medications. I also talked about my concern with obtaining large amounts of prescriptions in close proximity (1-3 days apart) from different providers that may not be communicating, and asked if she considered that she may be addicted. I offered her counseling and treatment for this as well. When I left the room, the patient and I were still friends. But that took a darker turn when she realized that she wasn't getting what she wanted.

I have heard you say previously that "I can't judge a patient's pain". I completely agree with this statement. But I CAN judge a patient's behavior, as well as physical exam findings. We are all trained in recognizing manifestations of pain. As with any other disease, the physical exam findings may not support the given history. Other clues such as vital signs, behavior when the patient does not think he is being observed, and conflicting history are all part of the history and physical that point us to what is going on. This is as true for opiate addiction masked as "chronic back pain" as it is for acute appendicitis masked as "gastroenteritis".

When that behavior poses a risk of death to the patient, I have a RESPONSIBILITY not only to not contribute to it, but to offer to help correct the behavior through treatment. As physicians, we must be strong enough to tell the patient what they don't want to hear, even if it risks making them unhappy. To do less is a disservice to the patient.
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