The Opioid Epidemic is Here.
I practice internal medicine. It’s what I do for a living. I love it, and needless to say, given the fact that you’re reading this on my blog this very moment, I also have other pleasures and interests. But I choose to stay in medicine because it’s what I’ve trained hard for- the resultant fruits of my labor.
Each day that I’m at the office, I see patients for a myriad of complaints spanning the length of the entire human body. I interact with my patients by saying hello, smiling, consoling, and sometimes even hugging, when it’s needed. See my article, Have You Hugged Your Doctor Today if you don’t believe it. I refer to them by name, and often ask about their loved ones. I value personal touch and I know that it’s mutual. I’m there for one thing, and one thing only. For the patients.
But then something big comes along; something that complicates the field I’ve worked in for so many years. Things have started taking a turn, you see- a veer off course from the linear continuum of medical healing- and it’s a turn for the worse. I’m watching from the sidelines, helplessly, not quite sure of what to do. I didn’t make this happen, after all. I didn’t set this off. Someone else did. And somehow, I’ve now been asked to clean it up. The Opioid Epidemic is here in full effect.
Treating Pain: Some Examples from Practice.
Of the patients I see in the office, I happen to treat many for pain on a regular basis. Let’s face it: we’re preaching for a more active lifestyle and subsequently, people do get hurt. They come in after making a wrong move, maybe twisting their back, or their hip or ankle, and now voila, they’re cringing in acute, unbearable pain.
“You must give me a pain medication, and quickly,” they say. Over the counters don’t work.
I get it. I empathize and so I do.
But when they come back, one month later, and say they’re in need of more, what then?
It’s fairly straight forward, one would think. My role here is to ease their pain. It’s usually a legit request, and so, once again, I relent. Of course, I discuss alternatives- the trial of alternate medications- or compresses, or good ‘ole rest. Then there’s the always necessary addictive-nature-of-pain-meds-that-has-contributed-to-this-epidemic talk. Yada-yada-yada. I go through the list of what I should be saying. But the bottom line is that I treat.
But is the treatment appropriate or have I simple ‘given in’? Who’s to say the patient is not actually addicted to his meds? Or abusing them? Who’s to say they’re not being sold?
Here’s some food for thought, dear reader: when does treating equal giving in? How can I truly make that judgement? It’s a call I never thought I’d have to make when I entered this field almost two decades ago. It seems, sadly, that lines have blurred, over the past few years, and they’re getting murkier by the minute.
When Acute Becomes Chronic.
It should be simple, even if not always so straight forward: if your patient is in pain, you treat them.
But what about a patient who’s been on opioids for years? How do you answer those who were led down the chronic opioid path by old school medicine, either rightly, or wrongly, so? Where do we draw the line?
Let’s consider an example.
A patient walks in asking for a pain med refill. He has had neck pain for years, and nothing has helped other than narcotics. His previous doctors gave him Percocets. Or Oxycontins. Or substitute whichever controlled substance you’d like here. What is my role in this given scenario, as doctor? Classically, I’ve been trained to assess and treat the patient- simple as that.
But enter dilemma of modern day medicine, opioid epidemic in mind. In this particular instance, as a PMD practicing today, I am expected to shed my doctor’s coat and stethoscope, while replacing them with the raincoat and magnifying glass of a sleuth. You can even add suspenders for dramatics. There’s only one problem: I have watched just a handful of episodes of Columbo in my youth and, while they were highly entertaining, I’m not quite ready to take on a role as understudy. I haven’t even rehearsed.
However, this growing epidemic now expects me to do just that- to put on my detective gear and start interrogations.
But how can I do that? Who’s to say would be correct? What if I miss an addict, and they in turn pass away of an overdose the following day? Or even worse, suspect ill of a patient, and miss treating his real pain? And what of the patient’s opinion of me? Who would stay with a physician who constantly questions their honesty?
It’s a lose-lose.
The truth of it is that assessing for pain is tough. It’s subjective. If someone says they’re in pain, we often expect them to look like they’re in pain. But I know better, not only because I myself have held back pain, but also because I feel like I should trust my patients.
Then there’s the issue of physical examination. I use it as an investigational tool, but it certainly has its limitations. A patient who is drug seeking can simply make up an ‘ouch’. Think about it. You move the leg up, a patient utters in pain, or grabs his backside. Who am I to judge whether that grimace is real? It’s enough to have to scan through a myriad of possible diagnoses in my head, all by memory, gained through years of education and training, but to also have to call a bluff? Even the best of poker pros make mistakes. Plus, in real life, it’s easier to give people the benefit of the doubt. We want to believe them. I mean, sure, many of us in the field can recount instances in which patients theatrically put on a show to get what they want. But what about the instances that weren’t quite so obvious? I guarantee numerous Oscar-worthy performances could fool even the most seasoned of practitioners. And we are, after all, medical providers, not detectives.
Let’s dissect the nature of filling a controlled substance request for a moment. Are you familiar with the procedure?
At some point during a 15 minute office visit, I must check on my patient’s previous and current usage of controlled substances by logging on to a separate databank on the web, a step mandated by the state. Once in it (after manual insertion of full name and date of birth), I peruse through a patient’s ‘record’. Even grandma Louise must be subjected to such a search. This is no simple task, and can take up quite a bit of time. I must then interpret information gained, and determine if said patient is legitimately asking for the medication, or possibly requesting their next easy fix. Followed, by the way, by a two-step verification process in which the medication is actually ordered. The details are lengthy, and involve not only entering my system password once again, but also providing a virtual ‘key’, a 6-digit number I obtain by using an app installed on my iphone.
Is this really what I signed up for when I took the Hippocratic Oath?
Yes, because I’ve promised to do no harm. If a patient is abusing, I should identify their addiction. I should help them with awareness, admission, and recovery.
But also no. I want to heal, but I’m not quite ready for police-work.
And when I do identify potential abuse, just how difficult can it be to tell someone they may have a problem? Extremely. How often does a patient actually admit to an addiction? Rarely. The very nature of coming in, asking for the mediation, is the cycle of abuse, in action. If I ever suggest there may be a problem, no one openly embraces my suspicion, with open arms and a smile, or a weeping confession. Unfortunately, this scenario is only encountered on Hollywood big screens, or in the dreams of naive medical students. Addicts don’t admit. Addicts lash out. They deny. They are genuinely surprised. They threaten. They scream.
I want to heal, but I’m not quite ready for police-work.
They even kill. Just read about Dr. Todd Graham of Indiana, 56 years old when he died for saying no to suc a script.
It may seem easy, to those of you on the outside, to identify those who may be abusing. But no one walks into my office and says, “Doc, please give me oxy to feed my addiction,” or, “Send a prescription in so I can get back on the streets and sell. My supply is running low.”
No. I didn’t sign up for this. I signed up to go to work every day, to heal. To help identify illness. To help alleviate medical conditions. To have a good rapport with those who seek my advice. To come to work with a smile and to leave with a gratifying sense of achievement.
I signed up to heal.
To read more commentary on the opioid epidemic, see my article, “The Doctors Who Did This Should Be Hanged,” & Other Statements from Behind a Screen.