Enough with the pain pills!
A nutritious start to a day on the couch!
Enough with the pain pills!
It seems as if every shift in the emergency department, I’m being accosted for pain medication. ‘Doctor, I’m dying,’ for the aches of the flu. ‘Doc, come one man, I have to have something,’ for the chronic back pain. ‘Doc, nobody has done anything for me!’ (After receiving the $10,000 work up for abdominal or chest pain, but then being denied the coveted narcotic.)
Yesterday, I told the patient with pneumonia I would give her pain medication, gave her morphine, told her I would give her medications at discharge (for pain) and still she looked up, plaintive, ‘but doctor, are you gonna’ give me anything…for…pain?’ Yes, yes, YES!
I’m sorry if you think I’m heartless. But I have never, in all of my 16 years of practice and preceding 3 years of residency, seen as many people so desperate for narcotic analgesics or anxiolytics (like Xanax, Ativan or Valium)!
We are constantly reminded that we physicians do a terrible job of pain relief. Joint Commission watches us, our specialty organizations remind us, the government monitors us (damning us for both giving too many and too few), lawyers threaten us; even administrators with patient satisfaction surveys prod us. But I’m telling you, we’re giving it out by the truck-load, from some bizarre, professionally dysfunctional combination of compassion and exasperation, and it isn’t changing a thing, except to keep the raccoons coming back to the trash cans.
Do we really live in a time in which pain is that much worse? Are we living longer with more severe illnesses and injuries? Are we more sensitized? Are we evolving into softer, less hardy individuals in a kind of mockery of traditional Darwinism? Or are there just more pills, and more enabling family members and professionals?
I mean, physicians in neurology, pain management, family medicine, emergency medicine, all across the pantheon (I know, we aren’t gods, but it sounded cool) of medicine are practically throwing narcotics and sedatives at the populace who incessantly demand them, starting in grade-school! The blame goes both ways. The demand is staggering, and the willingness to give prescriptions is epic.
USA Today recently ran a piece about the enormous problem of prescription narcotic abuse among the Medicaid population.
http://www.usatoday.com/news/health/2009-09-29-Medicaid-drug-abuse-fraud-Michael-Jackson_N.htm
I’m impressed that they would do this piece; I doubt if any academic medical center would do research on the topic. It just isn’t ‘nice’ to accuse patients of abusing and gaming the system…or, heaven forbid, of lying!
I think, perhaps, that’s the problem. Physicians and other care providers just don’t want to believe people will lie. Furthermore, even the word ‘lie’ seems regressive and judgmental to the modern mind. ‘Who are we to say what’s the truth and what isn’t,’ seems to be the line of disjointed logic.
I suggested this once, that patients lie, and a physician wrote to my editor and said, ‘who does Dr. Leap think he is to suggest that patients might lie?’ I wondered ‘Where do you practice, sister? Gates of Heaven Medical Center?’
Maybe this is why we give out so many pain pills and things for anxiety. We can expect a lot from ourselves. We can call up our fortitude and endurance; but we don’t expect the same from our patients, so we’re willing to let them develop or wallow in their addictions, all the while we continue to confabulate and obfuscate about imaginary pathologies and named diseases that have no confirmation by science.
If we are so very bad at pain, then fine; just legalize the whole ‘kit and caboodle.’ I think it’s a terrible idea on many levels, but honestly, if we did it then emergency department volumes (and expenditures) would drop like a rock. We wouldn’t have to spend time and someone else’s money trying to figure out how a bird flying overhead caused sudden, incapacitating leg cramps. We could just intubate overdoses and be done with it.
I find it instructive that a program like Medicaid has so much abuse. It’s no surprise. When a thing costs a person nothing, nothing in personal financial or moral outlay, then they will use and abuse that thing. Not only so, but in this particular case, they will take that thing and sell it on the black market, causing addiction in other individuals as well.
Read the USA Today article and weep for the future. When a thing is free, it will be abused. And that seems to be the case for narcotics as much as anything else in the world of endless, emotion-based, governmental compassion; always lacking consequences.
Except for those paying the bills and sorting through the lies.
Hi, Edwin. The problem for those of us who do not abuse pain medication is that when we really do need it, we are afraid to ask for it because of fear of being labeled. I have nothing but ibuprofen for pain in my house, but there are some days I’d just about give my eye-teeth for a percocet or something for anxiety (caused by high cortisol). But I don’t ask my physicians for it, because I don’t want the label. I want to be taken seriously.
Then again, it backfires sometimes. I have heard, “You must not be in too much pain if you aren’t taking anything for it.”
Sometimes a patient just can’t win.
Robin,
I agree totally! I understand your dilemma, and frankly I try my best to be responsive to the needs of those with genuine problems, like yourself. The problem is, there’s so much deceit! So many people who are simply recreational users (and sellers) of the medications that it’s a terrible morass. I think I speak for my group when I say that you wouldn’t have any problem getting medication from us.
I’d love to see those with genuine problems band together to expose and crack-down on the abusers. They make those who really suffer endure so much more!
Thanks for writing!
Edwin
I can’t take those meds. without becoming extremely nauseated. I recently had surgery, and ended up using Tylenol instead.
Dr. Leap,
I appreciate this article. It’s so aggravating sometimes to be called to a room over and over and over for someone sitting up in bed, watching tv, laughing with family, complaining of ABD pain, eating a cheeseburger, wanting their phenergan and Lortab, or morphine! What’s your pain level right now? Of course, it’s a 10! And you’re nauseated too? “Well, if I don’t get my phenergan, I will be”! Sigh. Meanwhile, Mr. So and So is down the hall patient as can be, not asking for a thing,,, DNR 3, or Mrs. What’s her name, pressure sores, no legs, can’t even feed herself, and not even asking for a tylenol!!!! Come on, what’s wrong with this picture? Your article is sooo true!!!
Thanks for sharing your experience. I’m with you that prescription medications are pushed too hard, and that a lot of them can be addictive.
We live in a time of unprecedented (yet still highly limited) knowledge of the brain, and greater ability to effect it than ever. Unfortunately, this leads to drug abuse.
All so true… except, please: It’s “the whole kit and caboodle”, not “the whole kitten caboodle”
Evan,
That’s what I get for writing just before I go to sleep! Thanks for the reminder. Although, I think a ‘Kitten Caboodle’ sounds intriguing, don’t you?
So true Ed…so very true. A well known ER recidivist who comes to the ER at least 5 times a month and demands narcotics for anything from migraines to abdominal pain ran down the hallway to the CEO’s office to loudly complain that my husband wasn’t giving her any of the pain meds she wanted. The classic allergic to everything patient. The CEO then called my husband’s boss, and the boss told the CEO that the patient should re-register to see another doc. The NEW doc also refused to give her anything. The administrative mantra is “make them happy at any cost, we want them to come back”, even if they aren’t paying a thin dime! Perhaps we should just open up a legal drug clinic, and the docs should have code names like “Pimpy”, “Huggy-Bear” and “Dr. Feelgood”. That way, the DEA won’t be sending you those love-letters that you gave 10 T-3s to someone who got 20 other doctors to write for 50 Vicodin with a refill! Damned if you do, damned if you don’t. WOW! That was a good rant for today.
Mrs. Berg-a-licious
I am not in the medical profession and it’s amazing to me to hear the other side of the ER room. Who are these people that have nothing else in their lives except to live on pain pills and abuse free medical treatment programs? Simply amazing but I don’t doubt it. Keep up the good work and enough with the pain pills. You’re doing society a service by not prescribing them!
A great post–and good comments too! I was working at a VA Hospital not long ago and it got to the point we had to make a firm rule: No narc refills through the ER, only through the primary provider. Sometimes, I felt like we were hurting patients who really had a good reason for running out, but we had to hold firm. Also patients doctor shopped even in the VA. I had a patient who recurrently arrived with a pain c/o and was out of meds. After one of his visits, I sat down and looked at his chart. On the VA’s electronic record, I was able to tease out that the patient was going to a neighboring state’s VA and getting drugs there. For a while, until I detected it and ratted him out with a note in the record that I cc’ed to his primary, he was getting full 30 day refills from us and the out of state VA. He was not happy when he had been detected and could not play the system any more–at least the VA system. No doubt he was haunting some of the private hospital’s ERs too looking for his fix. Patients who are addicted to these drugs lie, and lie repeatedly, to get what they want.
They are tough to love!
As a pharmacist, I agree somewhat with your post. However, there are things I disagree with.
First, no – our pain nor anxiety is not greater than in years, centuries before. But, availability of the drugs to treat them are less available. In centuries past, no household would be without laudanum, which is essentially Tincture of Opium. It had its justified medical uses – decreasing pain associated with reducing a dislocation or surgery to remove a foreign body. But, it was also common for folks to use it to ease melancholia – just like today actually.
Then, in the late 1880’s we saw the formulation and development of Coca Cola, which has a storied history. It contained cocaine for a few decades & still some contain caffeine. It was first sold as a patent medication for treatment of multiple disorders – melancholia & morphine addiction among them.
Even today, the plant which purchases & extracts the cola from the cocoa leaves is also the only plant licensed in the US to process cocaine which is then sold to Mallinckrodt which processes it into medical grade cocaine for distribution.
Finally, we have so many OTC medications to treat pain that now we are running into medical issues because of that – liver failure due to APAP, GI bleeds due to NSAIDS, children overdosing because mom or dad used too many medications or misread labeling. So, no – I don’t think our pain is more prevalent today than in the past. I do believe however we are inundated with ads which show our pain (physical or mental) can be easily managed by a pill – a result of direct to consumer ads. I also believe physicians don’t spend enough time talking about pain – what to expect, what to do if it worsens, why it exists at all.
I don’t mean to imply you need to do this as an ED physician, but many folks use you (meaning the general ED) as their PCP. As wrong as this is – it just is. So, we need to soldier on as best we can. I try to do my part on my end – in fact explaining and teaching is easily 25% of what I do.
Perhaps if you view these as teachable moments, they won’t be such a bitter pill to swallow????????
Linda,
Great historical information. Thanks for that! Although, I wonder what percentage of homes actually did have laudanum. I come from a rural Appalachian family and never heard of anyone having it. Nevertheless, your point is well made.
I agree, we could teach more. And often we try. But we’re met with this: ‘yeah, but, uh, can I get more Percocet now? I’m allergic to the 5mg, but not the 10mg ones.’ There is a huge population uninterested in learning, unconcerned with improving and functioning, and solely interested in the euphoria and/or street value of the drugs they seek.
I’d love to educate them, but they are resistant over and over.
Thanks for your excellent comment!
Edwin
Pills are an epidemic! Many physicians are simply glorified drug dealers. I work in an assisted living facility and my husband works at an area hospital. The public would not only not believe the pill abuse, some would dismiss it as lies. There needs to be some accountability from not only physicians but pharmaceutical companies. It is a shame that medicine is dying as an art in exchange for it being a giant business venture.
Edwin, I can see you are a true doctor of medicine. Thank you for being outspoken against this pill plague. You have great strength against the machine. I wish you well and hope you can make a change.