Sure, It’s My Fault by Pat Conrad MD
Dear prospective medical student: Before you decide to embark on this career path, ask yourself, “Do I enjoy always being the bad guy?” If the answer is yes, then you are on the right track.
Over the past year, a patient seen at one or more of the hospitals where I work received prescriptions for the following: 765 Lortab, 105 dilaudid, 600 Xanax, 459 oxycodone, and 120 tramadol, from hospitals throughout the region. When this patient has not gotten the meds he/she wanted, she/he raises hell, family members call and raise hell, and even local politicians make inquiries about this patient’s pain not being treated. Obviously nothing, NOTHING justifies this level of prescription abuse and docs should slam the gate on this fraudulent activity (I did, and this patient doesn’t even bother arguing with me anymore). But no doubt this patient works a wide enough area so that at least some docs in busy clinics or ER’s won’t realize how bad the problems is. There could be serious addiction-type abuse happening, diversion for family members, outright selling on the street, and almost certainly it’s all of the above. And the potential is rising that on the day this piece of work is arrested for dealing, or dies of a drug overdose, the enforcement agents, local media, family members, compassionate lawyers, and even colleagues will all level the finger at the last poor sap to write a narcotics script. And do not expect your local hospital to come to your defense.
From the Charlotte Observer last month: “Will doctors prescribe fewer painkillers?” “After the N.C. Medical Board suspended his psychiatrist for writing inappropriate prescriptions, Douglas “Chip” Kimel III found a new doctor to continue his treatment for attention deficit disorder – oxycodone, a powerful and potentially addictive painkiller.” And 18 months later, Kimel was dead after filling a script for 300 oxycodone from a replacement doc, selling it for heroin, and voila, OD City.
It is evident that Kimel saw a couple of different quacks, and that oxycodone is not a very good ADHD remedy. If you are tempted to jump on me for defending doctors who fling addictive substances at every problem, then save your breath because I’m not.
Cases like the two above are being used to drive tighter state and federal opioid prescribing guidelines. The up side is that these can be used – maybe – as a defense against criticisms or lawsuits alleging under-prescribing for “real” conditions. The down side is that if one goes beyond those guidelines and there is a bad outcome, or evidence of diversion, then one might be sued, be subject to government fines, or even lose one’s medical license. It will further constrain the actual use of a physician’s judgment in treating patients.
While being ripped by addicted, fraudulent, or just plain whiny patients on one side, and increasingly threatened by government and state medical boards from the other side, physicians will still be made scapegoats for bad patient behavior. In some cases blame will be richly merited. But in this grade-school logic society where the one noisy kid gets recess cancelled for everyone, I’m tired of being collateral damage.
F-ing A.
Like the great majority of doctors, I try to get it right – prescribe pain meds to the patients who need them and not to patients who will abuse or divert them. In the late 90’s we were pushed to overprescribe through pain “initiatives”, Press-Ganey scores, JCAHO, fifth vital sign, Purdue Pharmaceuticals, etc, etc. I recall reading an article where a physician was disciplined for not prescribing hydromorphone to a mock patient sent to him by the state board (I think it was New York). Of course that approach was unsustainable and led to rampant abuse.
In what appears to be mass amnesia on the part of governments and state boards to their own contributions to the problem, the pendulum has now swung the other way. I hear physicians boast of completely refusing to prescribe narcotics. This includes many pain specialists who “don’t believe” in pain medicines except for gabapentin and tramadol, and they’re not too sure about tramadol. Often after failing to control the patient’s pain they send patients back to the family physician, who either can tell the patient they’re SOL or prescribe something for their pain. Online prescription monitoring programs meant to identify med abusers are used instead by medical boards to go after high prescribers even in the absence of complaints against them.
I am not defending the pill mills, the physicians that overprescribe just to make a buck. It should be evident though that attempts to help physicians to get it right often lead to getting it wrong. God bless police and law enforcement, but their priorities are much different than a physician trying to do the right thing for the patient sitting across from him in the exam room.