The last doctor gave me that "D" medicine...

by Bob Stuntz

There has been a fair amount of discussion recently about the national epidemic of prescription drug abuse in the United States.  I recently read an interesting article in EM News on the topic.  I have some personal opinions on the subject, and I feel that this is an important topic for Emergency Medicine Residents and Registrars to consider.  

First, I notice frequently that we refer to the medications for which we write as “narcotics.” This sends a shiver up my spine.  I have been told that at one point, pharmacologically “narcotics” referred to any drug with sleep inducing properties.  In the United States’ common vernacular, it has become a legal term.  Narcotics by US legal definitions include cocaine and heroin.  While I understand that amongst physicians we know what we mean by this, remember that our patients knows narcotics from TV (do you think when they say Narcotic on “Law and Order,”  they are referring to legally obtained prescriptions?).  I think when we refer to these medicines as narcotics, to the lay person we are associating ourselves with illegal drugs, making us look even more like the drug dealers inflicting this scourge on society.  I am not a drug dealer.  I would submit that we should avoid referring to what we prescribe as narcotics, and I try my best to do so myself.  (We all slip of course!)  

The question is always who is to blame for the skyrocketing abuse of these medications?  I was taught that pain was the 5th vital sign, and spent residency seeing articles in how bad we are at addressing pain in the ED.  Now I am told I am responsible for killing and addicting my patients.  What are we to do?  As a resident, you hear both sides.  Every attending with whom you work will have a different opinion.  It is going to be your job to synthesize those opinions and develop your own practice.  

I personally rarely will write for more than 1-2 day’s worth of opioid and opioid like analgesics (obviously there are exceptions to this).  I believe in this especially in the “abdominal pain NOS” and other NOS (not otherwise specified) groups, where your prescription may mask pain that should prompt their return to the ED.  I know there are other EP’s who will write for more or less.  I also hear blame placed on primary care providers.  I think we as physicians should stop trying to blame each other as there is not one group at fault for the problem.  It is clearly multifactorial.  I think there are a few things we can do to address the problem from our standpoint and make our treatment of pain better and safer for us and our patients.    

1. Talk with your patients.  Acknowledge their pain, treat them in the ED, and discuss prescription options.  We should be telling our patients of the side effects of prescriptions opioids/opioid like analgesics (constipation, overdose, addiction, impaired function, masking concerning pain).  Explain your recommendations.    

2.  Review patient records and drug databases if available.  If they are doctor shopping or shuttling prescriptions, recognize this and don’t compound the problem.  

3. Try to avoid treating Press-Gainey.  Remember, we are doctors and not concierge at the Bellagio.  If it takes a few minutes to sit down and discuss pain management with your patient, it is worth it to avoid blindly throwing Vicodin at someone who may abuse it (or let it get in the hands of their kids) just because you feel like it will make them score you higher.  This gets into the issue of people rating their doctors like a customer service industry in general, which is a debate all its own.  I know this issue is not so simple, but I think it is something that is important and that we should all talk about.  

4.  Do not punish patients who truly need it because you think everyone asking for pain meds is a “drug seeker.”  Just because the terminal cancer patient is asking for dilaudid does not mean he/she is a “drug seeker”  in the classic sense.  Perhaps they are seeking drugs because they are truly in pain.  This leads to my last point:

5.  Treat each patient as an individual with a fresh set of eyes.  One day, that “drug seeker” may going to come in with something catastrophic, and you do not want to miss that.  Just because your last 3 patients were scamming you does not mean the fourth one is doing the same.  Take each complaint seriously.  If you evaluate them and determine they do not have an emergency medical condition, by all means hit the brakes.  If you do not want to be treated like an illegal drug dealer, then do not treat your patients like an illegal drug buyer.  

ACEP recently released a clinical policy on the topic that I think presents reasonable recommendations.  This is obviously a controversial topic, and there are no absolute right answers.  As a trainee, you need to evaluate your own beliefs and learn from your supervisors.  But above all, remember, your job is to do what is right for your patients.  Do that, and you will never go wrong.