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Old 02-02-2011, 02:25   #16
Doczilla
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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.

'zilla
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Old 02-02-2011, 02:37   #17
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Quote:
Originally Posted by Doczilla View Post
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,
Doc, please tell me if this line is good to go. A surgeon taught me recently.
"No one has ever died from pain, but too much of this (fill in the blank) and you'll eventually flat line. Now, which one would you have?"
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Old 02-23-2011, 04:04   #18
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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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Old 03-06-2012, 07:49   #19
DocIllinois
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Part of the problem with a lot of the pain meds out there is that the user develops a "tolerance" to the meds effectiveness, so like any other type of addiction, more is needed to get the same effect.
I've had patients who have been in just this predicament, seeking relief from service related musculoskeletal pain or injury.

I say good work, General.
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Old 11-27-2012, 14:27   #20
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My wife just recently had her gallbladder removed and a hernia repair. It was all taken care of by laparoscopic procedure. The procedure took less than one hour, we were home in about three hours. The surgeon provided 40 pain pills (norco). My wife took three and threw the rest away.
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Old 11-28-2012, 13:06   #21
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My wife just recently had her gallbladder removed and a hernia repair. It was all taken care of by laparoscopic procedure. The procedure took less than one hour, we were home in about three hours. The surgeon provided 40 pain pills (norco). My wife took three and threw the rest away.
Good for her, sounds tough. Throwing away, flushing . . . Not so good.
Most hospitals,pharmacies, some police stations accept them for disposal. Twice a year there is a Prescription Take-Back Day across the country where you can securely rid your home of unneeded drugs to be safely disposed of.
Flushed down the toilet they re-enter the water system. Who wants fish goin' around sayin' "hey, man . . . "
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Old 11-28-2012, 14:25   #22
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Good for her, sounds tough. Throwing away, flushing . . . Not so good.
Most hospitals,pharmacies, some police stations accept them for disposal. Twice a year there is a Prescription Take-Back Day across the country where you can securely rid your home of unneeded drugs to be safely disposed of.
Flushed down the toilet they re-enter the water system. Who wants fish goin' around sayin' "hey, man . . . "
Or... send me a PM and I'll give you my snail mail adddress! (FOGs need pain meds... just because they're FOGs.)
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Old 11-29-2012, 00:58   #23
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Who wants fish goin' around sayin' "hey, man . . . "
I do. They are dumber and have the munchies.

All joking aside it is tough call. Some people have the addiction gene and become addicted but have real pain that needs to be treated. Telling them to tough it out is not good medicine. People with real chronic pain have a high rate of suicide and depression. Add to the fact they can not sleep well that affects their whole lives. The key is to get the balance of dose vs side effects right. Where does the pain relief end and getting high begin? It is different with everyone and can change day to day depending on the cause of the pain. Lots of gray areas and there is no simple solution. I applaud the General for telling a no shit problem that we can all learn from.
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Old 01-22-2013, 15:22   #24
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I have told my patients that my goal is to resort function, not to get them free of pain. Likely they will never be completely pain free. I try to get them to readjust their goals. Some want the help, some don't. For those that don't, I'm ok with their decision but I'm not the provider for them.

My thoughts on addicts is that they are trying to self medicate either psychiatric or physical pain. Not just narcotics or alcohol but any addiction. If we can find the root we can decrease or eliminate the addiction and restore their functionality.

I followed a provider at a community health clinic that gave out narcs like it was candy and our reputation showed it. I came in with the mandate to turn it around. We had people coming from Pheonix and flagstaff to nm for narcs.

I would listen to their S&S and review test results if any, order tests, PT, refer to physiatrist put them on a pain contract. If they broke the contract, I'd drop them quickly with a 2 week supply so they can try to find another provider.
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