The Opioid Epidemic is Here
I practice internal medicine. It’s what I do. I love it, and, needless to say, given the fact that you’re reading this on my blog right about now, 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 them, when it’s needed. 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’s should be simple, even if not so straight forward: if your patient is in pain, treat them.
But what about a patient who’s been on opioids for years? How do you answer to those led down the chronic opioid path by old school medicine, either rightly, or wrongly, so? Where do you draw the line?
Let’s consider an instance.
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. 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 2017:, Opioid Epidemic in mind. In this particular instance, as a PMD practicing today, I’m now expected to shed my doctor’s coat and stethoscope and replace them with the raincoat and magnifying glass of a sleuth. Add suspenders for dramatics. There’s only one problem: I’ve only watched a few episodes of Columbo in my youth and, while they were highly entertaining and even somewhat comical, I’m not quite ready to take on the 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 this? Who’s to say I’ll be correct? What if I miss an addict, and they in turn die of an overdose the following day? Or even worse, suspect ill of a patient, and miss treating his real, existent 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.
Assessing for pain is tough. It’s subjective. If someone says they’re in pain, we 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 want to 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 an honest one? 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? Let’s face it- even 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 comical instances in which patients busted out obvious theatrical moves 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 practitioners, and not detectives.
Let’s dissect the nature of filling a controlled substance request. Do you know what I must do, after one is made?
At some point during a 15 minute office visit, I must check on my patient’s controlled substance status/previous use, by logging on to a separate databank on the web, which has been mandated by my state as proper. Once in it (after appropriate full name and date of birth has been manually entered in), 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. I’ll skip details for brevity’s sake, but note that it cannot be skipped at the time of visit, but only here in discussion.
Is this really what I signed up for when I took the Hippocratic Oath?
Two answers come to mind, but unfortunately they conflict. The first is yes: 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 it’s not as easy as typing the words on this post, or reading them aloud. It’s actually darn hard.
How difficult can it be to tell someone they may have a problem, you ask? Extremely. How often does a patient actually admit to an addiction? Rarely. The very nature of his coming in, asking for meds, is often an indicator of loss of control. 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 and nighttime dreams. Addicts don’t admit. Addicts lash out. They deny. They are genuinely surprised. They threaten. They scream.
They even kill. Just read about Dr. Todd Graham of Indiana, 56 years old when he died for saying no to 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.”
The second answer to my previous question is one which comes more naturally to my lips- NO. I didn’t sign up for this. I signed up to go to work every day, and 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.
No, I didn’t sign up for this. I signed up to practice medicine and to rid patients of their pain.
The Doctors Who Did This Should Be Hanged
It’s a statement the came at me with a bang.It stood out in its thread, in the accusatory way of old courtroom scenes of black and white movies, where the heroine dramatically screams out at the jury, seated wide-eyed in their box nearby.
But it was merely a response to a Facebook post on this very same topic, typed in nonchalantly, by a peaceful-looking individual, who had clearly had their buttons pushed and was subsequently irate. I don’t think she meant harm by it, but it hit me like a ton of bricks. I thought about her accusation long and hard; about all the accusations on the thread.
The doctors who did this? Have we honestly ‘done this’? Why am I lumped into a collective, and deemed responsible for something grand like an epidemic, when I slave through patient after patient, and do my due diligence of the searches and actions described above? Have I failed at something and not recognized it?
More quotes from the general public on this matter, screaming at me from the computer screen, as if typed in all-caps, below. Under each one, my visceral reaction:
“Doctors like this all over the country are running mills.”
(I’m not. But I prescribe pain medications and am now fearful of being labeled and blamed, thanks to accusations like this).
“Yes, the doctors and big pharmaceutical companies fueled the opiate epidemic, and guess who is making billions off of rehab drugs like suboxone? You guessed it those same doctors and big pharmaceuticals.”
(Doctors make billions? How exactly does my prescribing a medication result in money directly in my pocket? I don’t benefit from a prescription monetarily. I do, however, admit to an emotional benefit when my prescriptions result in lowering blood pressure. Or normalizing glucose levels of a diabetic. Or making pain disappear. We’ll leave out cholesterol levels at this time because of the growing trend to suddenly blame doctors for ‘greed’ in prescribing statins to lower patients’ cholesterol levels and heart disease risk. It all seems to be a conspiracy.Except that no one’s filled me in on the plot, and I’m actually one of them).
(Plus, is it just me or do faceless accusations seem to be the biggest ‘in’ thing on social media these days?)
“The opioid problem in this state starts with the doctors overprescribing them.”
(What defines ‘overprescribing?’ Under which scenario would an over-prescription be an accurate description? If Percocet is to be taken every 4-6 hours, as is FDA-approved, is it not legitimate that one quite possibly prescribes a larger supply? Should I negotiate the number of tablets, much like the sale price at an auction? If not, does the patient need a return visit for more? Because I know what takes place when this happens. The patient says, “The doctor is only making me come in for a co-pay.” He then subsequently rates me poorly on the mail-home patient survey, which comes back full circle to kick me in the ass, since government ironically plans to change reimbursement based on scores in patient satisfaction, recorded on this very same survey. A catch-22, to say the least.)
“Our society has changed. People are now told they don’t have to deal with any discomfort or problem. We supposedly have a solution for everything. So someone who has pain rather than deal with it goes to the doctor and gets something to make the pain go away. 50 years ago it was deal with it until it’s gone.”
(This actually makes some sense, and I agree with some of it. But the bottom line is that I practice medicine, and, to some degree, am here to serve. If someone stands before me, in pain, asking for an appropriate ‘next’ medication, and that medication is controlled, who am I to tell them to ‘just deal with it’?)
“Doctors are drug dealers in white coats”
(Drug dealers? Is this also true for antibiotics that make you better? Or for anti-depressants that make you better? Or diabetes medications that make you better? What is it about our line of work that makes us so vulnerable to criticism? What has turned us into dealers in the eyes of the public, especially now, when we’re equipped with a magnifying glass to weed out those who have grown dependent or actually abuse?)
“Doctors all over this country are getting people addicted” and “About time the doctors get the blame for this epidemic”
(Ouch. A collective accusation, once again, and it hits right where it counts.)
What strikes me to the core is the fact that the general public has stopped seeing us as the healers, and started viewing us as the drug dealers. We are now the enemy. It leads me to ask the following:
When did we who practice medicine, and mean no harm, actually start doing exactly what we swore not to do? When did we turn into the bad guys and how do we revert back to the good ?
This all happened because we tried to help. I imagine patient X, the first narcotics patient, who stood in front of his doctor, cringing in pain, who was subsequently made to feel better by that little blue paper, signed illegibly (an attempt to infuse some comic relief into this serious post) and traded in at the pharmacy for gold. When the patient thanked him for his miracle treatment, the doctor must have thought, Eureka! Boy, was he wrong.
The blame also came about because we have 15 minute slots in which to resolve patient problems, which, when they happen to be pain, can be tough to tackle. Because there aren’t many effective alternatives. Because we haven’t been properly trained in identifying and, more importantly, confronting head on, the issue of dependence and addiction. Because we don’t enjoy confrontations. Because we want our patients to leave happy.
These somehow all combined and turned us into the bad guys.
I believe I speak for all doctors when I say that we didn’t mean to contribute, even if we did. It was unintentional. I can confidently say that most of us are in this to heal and make things better. It’s what I’d like to think, and for the most part, it stands quite true. We all swore an oath, and are upheld to an unspoken ethical code of conduct, which we practice every single day.
I’m sorry that you think I’m responsible for the epidemic, and that all doctors are in it for greed. If you take a moment to think of all we’ve sacrificed to be where we are today, maybe you’d think twice about the placement of such blame. I don’t ever want to turn anyone away, but I also want to practice safe medicine. More importantly, I want to fix this terrible epidemic, along with everyone else around me, so I’ll keep on chugging and plugging into those searches, asking for urine samples, and sometimes simply saying no. Even if I’ll make a few mistakes along the way, I know I’ll at least have put in the effort, using the best of my judgement. If I have the best intentions at heart, hopefully I’ll make a difference in someone’s life.