Doczilla is offline
Join Date: Nov 2006
Location: OH usually, Iraq at the moment
First, I believe the general has demonstrated an immense amount of strength and character coming forward about his addiction. Hopefully this leads many more soldiers to consider doing the same when they get to that point.
Prescription drug abuse is a constant issue here. On the one hand, there is ample research that shows what a poor job we are doing at treating pain. A great deal of time has been spent educating physicians and MLPs about aggressively treating pain. The pain scales (most useless thing ever) were developed, and now nurses have to reassess it every hour by JC recommendations. It's good that we are paying some attention now, not allowing people (particularly older people) to suffer needlessly.
On the other hand, we have developed some unrealistic expectations on the part of the public. The expectation that I can make the pain of a fracture completely disappear with administration of a medication. That they should never have any pain of any severity, and that the presence of such requires a medication. That nothing will work for pain that could be obtained over the counter. That they always deserve a prescription for a narcotic simply because they came to the ER. That they know what they need for their pain, and are entitled to a narcotic because they asked for it.
Then, of course, we have a large number of people who's anxiety and depression accompanies or manifests as physical pain, and who medicate those mental health disorders with narcotics.
Chronic pain issues abound. Our anesthesia colleagues, particularly those who are fellowship trained in chronic pain management, have a phenomenal set of tools to treat these conditions. For those who can afford it, patients can get specialized care and improved quality of life with the least amount of narcotic necessary. Unfortunately, access to this level of care is limited in this area by insurance and the ability to pay. So many simply turn to the ER to manage their pain. We in the ER are excellent at treating acute severe pain, for which narcotics are frequently used effectively and with minimal complications. For chronic pain, however, we are ill equipped, and an appropriate plan for breakthrough pain of a chronic pain condition can be difficult to come by without considering a narcotic, particularly if we just met the patient. For our recidivists, we have developed "care plans" which spell out what we will and will not do for them, including what can or cannot be prescribed, as well as our expectations of them managing their medical care.
There are so many pill mills these days where you line up, walk in, and get your script for piles of narcotic pills for your "chronic back pain" without imaging, physical therapy, and other nonnarcotic therapies. These disgust me, as they do my ER and pain management colleagues. This is nothing short of a criminal enterprise in my opinion. As one of the drug task force officers said to me one day, "If you walk into a doctor's office and they have a bouncer, there may be a problem."
Here we have a statewide prescription drug database called the OARRS, or Ohio Automated Rx Reporting System. Every addictive substance filled in the state is entered into this database, so you can quickly call up a list of what this patient has been prescribed in the last 2 years, who wrote it, how many they got, where they filled it, and how they paid for it. It is now linked with several other states, and has been an amazing tool for intercepting drug seekers in the ER. It gives me the backup I need in the face of patient satisfaction scores and literature on poor pain control and patient expectations to say, "no".
A study was recently published showing the utility of the system. When the ER doc was provided a copy of the patient's OARRS report, it changed the amount of medication he was going to prescribe 40% of the time. Of these, he wrote less (or no) narcotics about 2/3 of the time. 1/3 of the time, he wrote more. It showed that just knowing about what they are taking helped the ER doc prescribe what he felt was appropriately.
On a hellishly busy ER shift, it is sometimes just easier for some folks to write for 10 vicodin to get the patient the hell out the door. I can't say I haven't done it. For me, I like to explain why a narcotic is not appropriate (citing literature), why I can't write any (because they see a pain specialist, who will fire the patient from the practice if I do), and in some cases, I express my concern over what appears to be a large number of narcotic prescriptions obtained from multiple providers over the last year, and would they like to speak with a social worker about a rehab program? If they are jumping docs a few days apart, I just call the police. There is an exception to the HIPAA rules that allow you to violate confidentiality if the patient is committing a crime on your campus. Any of the above helps to defray the inevitable confrontation from the irritated drug seeker and send them home.
You may find me one day dead in a ditch somewhere. But by God, you'll find me in a pile of brass. -Tpr. M. Padgett