Doctors' Dilemma: Prescription Pain Medications
http://www.100md.com
《美国整骨期刊》
Athens, Ohio
A patient came to me with the following complaints: a tragic wound obtained in Iraq, terrible pain, nightmares induced by posttraumatic stress disorder (PTSD), and a lack of compassion and care on the part of the United States Army. Moved by my patient's plight, I agreed to adjust his pain medication to a higher dosage, and I gave him contact information for a colleague in his area who had connections with groups that offer counseling for people with PTSD. As a veteran myself who served in Iraq for a year, I hugged the patient and told him that we would help him as fellow brothers. I left the office feeling pretty good that I had helped start the healing process for a fellow warrior.
A subsequent phone call with my colleague sobered me immediately, however.
Without disclosing the patient's identity—which would be a violation of the Health Insurance Portability and Accountability Act (HIPAA) that could result in jail time for me1—I told my colleague that a patient with PTSD symptoms might be calling him for help. Based solely upon the general details I provided about the patient's condition, my colleague said he strongly suspected that the patient was the same individual who had previously been dismissed from several other practices for drug-seeking behavior. Just to further brighten my day, my colleague told me that if indeed it were the same patient, I would likely be called as a witness in a US Army criminal investigation.
Two things have struck me squarely since I returned from overseas. The first is that the population seems to have gained two decades in age. I see far more elderly patients in the emergency department and in my clinic than I did before I left. The second is the high number of patients I see who are being prescribed serious narcotics for relatively minor problems. Very few of these patients are enrolled in formal pain-management programs, and of those that are, it is relatively easy for them to find physicians who will fill additional prescriptions without the knowledge of their pain specialists.
Physicians are in a terrible quandary. If a patient is "doctor shopping"—that is, seeking care from multiple physicians for the purpose of obtaining multiple prescriptions for controlled substances—and if the physician is aware of it, that physician is in knowledge of a felony. As such, the physician is obligated to report it.2 However, as soon as the crime is reported, the physician faces a great deal of time in court as a witness, as well as the ire of his colleagues who also find themselves in court because of their unwitting participation in a drug seeker's efforts to illegally obtain and use narcotics. Failing to report a felony is a crime that could get physicians relieved of their licenses and subject them to criminal penalties.3
Physicians also face the dilemma of wanting to help legitimate pain sufferers without having the ability to determine who is lying and who is telling the truth about their pain. I have found myself having to explain my "harsher" approach to patients who wonder why, after years of using acetaminophen/oxycodone (Percocet), they now must see pain-management specialists. I tell them that, as in junior high school, a few misbehaving individuals cause everyone to pay a price. I no longer prescribe any scheduled or controlled medications without a demonstrable fracture or history of cancer, unless I first consult a pain-management expert.
There are many nonnarcotic options available for patients, but the protests are legion when I suggest them. I have been verbally assaulted by a patient in the emergency department for not prescribing a narcotic to that individual, who had failed to keep a pain-management referral and who had been seen at several other emergency departments. I have also been confronted by a patient who I initially thought had legitimate pain complaints but whose subsequent urinalysis indicated the presence of tetrahydrocannabinol, the active compound in marijuana, but not the presence of opiates—despite the fact that the patient had been using oxycodone hydrochloride (OxyContin) for years under the care of another physician. He tried to explain these findings by pleading, "You understand, doc, I just smoked some pot. Come on, doc. It was just pot!"
I replied, "No, I do not understand. I spent a year away from my wife and kids, lost three friends between Iraq and Afghanistan, and had a young man I have known since he was a baby lose his leg to an IED [improvised explosive device]. I am drug tested yearly, and I have never used drugs. No, frankly I do not understand. By the way, where is your OxyContin going if it isn't in your urine"
Examples such as this kind can further jade a physician against future prescribing, even in the face of seemingly legitimate pain.
The United States has poured billions of dollars into an international "drug war," while it has virtually ignored the fight at home. Every day in this country, drug dealers, users, and traffickers show up in physicians' offices, playing against physicians' sympathies and our legal mandate to address patient pain in a timely and appropriate manner. These criminals take their prescription medications (many of which are paid for by state Medicaid programs for the poor) and walk out to sell them for cash,4 as some of my own patients have admitted to me. The only difference between these cases and instances in which the Medellin drug cartel pumps our kids full of cocaine is that the former cases are conducted under the guise of medical legitimacy.
Data for retail and mail-order pharmaceuticals reveal that acetaminophen/hydrocodone (Vicodin), which is a narcotic pain reliever, is now the numberone prescribed drug in the United States, with atorvastatin calcium (Lipitor), a medication used to lower elevated cholesterol levels, running second.5 In my area of the country, Vicodin sells for about $10 a tablet on the street, according to some of my patients.
The most serious problems occur when addicts show up at clinics and demand specific drugs under threat of harm to nurses or physicians. Such threats have happened to some of my colleagues. I did not spend the better part of my youth in school to face threats from drug addicts. It is truly enough to cause a person—and it has caused me—to start looking at other ways of making a living.
There is a solution to this problem, but like many solutions, the implementation of it after years of neglect will not be easy or pleasant. I offer the following four suggestions.
First, the federal government must mandate that computer systems link all pharmacies that dispense controlled substances. When a patient solicits the same medication from several different pharmacies, the pharmacist is immediately alerted as soon as the prescription information is entered. Pharmacists should then be required to report this data to law enforcement authorities.
The federal government should also mandate—just as it has with HIPAA—that practitioners who prescribe controlled substances comply with a federal standard for tracking the use and effectiveness of those substances. These records should be clear and comprehensive so that when the Drug Enforcement Administration needs to investigate alleged abuse, it can readily form a paper trail to prosecute drug abusers.
In addition, federal programs such as Medicaid and Medicare must mandate that each recipient of federal assistance for medical care has an assigned family physician. I know from personal experience that many patients seen in emergency departments have no family physician. Therefore, it is fairly easy for them to go from one emergency department to the next, collecting drugs without being caught. Currently, there is little or no surveillance of Medicaid patients using emergency departments as their sole source of medical care. I have seen certain Medicaid patients use the emergency department as many as 23 times in one month for minor health problems, and nobody from social services ever called to inquire why. This is not only terribly abusive of the taxpayers, whose money is used to help people in need, but it is a huge drain on federal resources that are needed to care for the truly needy and the growing elderly population.
Finally, the pharmaceutical companies that manufacture medications for chronic pain must be challenged to produce more medications like morphine sulfate (Avinza),6 which is a time-released opiate sold in capsule form. Avinza is excellent for severe pain but produces no "rush" or euphoria like OxyContin tablets; therefore, it has no street value. By contrast, the current street value of OxyContin is about $1 per milligram, and a prescription for OxyContin (40 mg) taken twice daily for a month is worth $2400.4 In general, capsule medications are less valuable than tablet medications, because tablets are easier to divide, "cut," or otherwise tamper with than capsules, leading potential buyers to have doubts about the drug's safety and efficacy.
I believe that the abuse of prescription medications by patients has reached the level of a national crisis, resulting in wrecked lives, neglected children, violent crime, injured police officers, and deaths of addicts. This crisis also affects every patient in the country—as one of my own patients found out recently, when after years of caring for her for arthritis, I told her I now had to refer her to a pain-management expert. I explained, "I do not have a pain meter in my head, and I can't tell who is or is not telling me the truth [about their need for pain medication]."
The longer the United States delays in establishing strict criteria and digital monitoring of the use of pain medications, the more likely it is that the average person in need of such medication for pain control will be confronted by physicians who refuse to prescribe without a consultation. This situation does not help patients in need of care and it causes grief for those of us who have made the care of the suffering our profession.
However, there is one alternative. It is terribly unpalatable, but if the United States refuses to treat the drug problem as a true national crisis, then the only option, in my opinion, is the full legalization of narcotics. I have struggled with this conclusion, but I believe that making these drugs legal would lower their value through market pressures, removing the financial incentive for the people involved in making and moving these substances. I shudder at this thought, but it is the sad truth and one that, after serving my country in Iraq, I wish I did not have to return home to.
Footnotes
As the premier scholarly publication of the osteopathic medical profession, JAOA—The Journal of the American Osteopathic Association encourages osteopathic physicians, faculty members and students at osteopathic medical colleges, and others within the healthcare professions to submit comments related to articles published in JAOA and the mission of the osteopathic medical profession. The JAOA's editors are particularly interested in letters that discuss recently published original research.
Letters to the editor are considered for publication in JAOA with the understanding that they have not been published elsewhere and that they are not simultaneously under consideration by any other publication.
All accepted letters to the editor are subject to copyediting. Letter writers may be asked to provide JAOA staff with photocopies of referenced material so that the references themselves and statements cited may be verified.
Readers are encouraged to prepare letters electronically in Microsoft Word (.doc) or in plain (.txt) or rich text (.rtf) format. The JAOA prefers that letters be e-mailed to jaoa@osteopathic.org. Mailed letters should also be sent electronically, in one of the aforementioned electronic formats on an IBM-compatible CD or a 3-inch disk, and addressed to Gilbert E. D'Alonzo, Jr, DO, Editor in Chief, American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864.
Letter writers must include their full professional titles and affiliations, complete preferred mailing addresses, day and evening telephone numbers, fax numbers, and preferred e-mail addresses. Authors are responsible for disclosing financial associations and other conflicts of interest.
Although JAOA cannot acknowledge the receipt of letters, a JAOA staff member will notify writers whose letters have been accepted for publication. Mailed submissions and supporting materials will not be returned unless authors provide self-addressed, stamped envelopes with their submissions.
All osteopathic physicians who have letters published in JAOA receive continuing medical education (CME) credit for their contributions. Writers of original letters receive 5 hours of AOA Category 1-B CME credit. Authors of published articles who respond to letters about their research receive 3 hours of Category 1-B CME credit for their responses.
Although JAOA welcomes letters to the editor, readers should be aware that these contributions have a lower publication priority than other submissions. As a consequence, letters are published only when space allows.
References
6. Avinza (Ligand). RxList Inc Web site. December 8,2004 . Available at: http://www.rxlist.com/cgi/generic/avinza.htm. Accessed October 6, 2005.(Todd Fredricks, DO)
A patient came to me with the following complaints: a tragic wound obtained in Iraq, terrible pain, nightmares induced by posttraumatic stress disorder (PTSD), and a lack of compassion and care on the part of the United States Army. Moved by my patient's plight, I agreed to adjust his pain medication to a higher dosage, and I gave him contact information for a colleague in his area who had connections with groups that offer counseling for people with PTSD. As a veteran myself who served in Iraq for a year, I hugged the patient and told him that we would help him as fellow brothers. I left the office feeling pretty good that I had helped start the healing process for a fellow warrior.
A subsequent phone call with my colleague sobered me immediately, however.
Without disclosing the patient's identity—which would be a violation of the Health Insurance Portability and Accountability Act (HIPAA) that could result in jail time for me1—I told my colleague that a patient with PTSD symptoms might be calling him for help. Based solely upon the general details I provided about the patient's condition, my colleague said he strongly suspected that the patient was the same individual who had previously been dismissed from several other practices for drug-seeking behavior. Just to further brighten my day, my colleague told me that if indeed it were the same patient, I would likely be called as a witness in a US Army criminal investigation.
Two things have struck me squarely since I returned from overseas. The first is that the population seems to have gained two decades in age. I see far more elderly patients in the emergency department and in my clinic than I did before I left. The second is the high number of patients I see who are being prescribed serious narcotics for relatively minor problems. Very few of these patients are enrolled in formal pain-management programs, and of those that are, it is relatively easy for them to find physicians who will fill additional prescriptions without the knowledge of their pain specialists.
Physicians are in a terrible quandary. If a patient is "doctor shopping"—that is, seeking care from multiple physicians for the purpose of obtaining multiple prescriptions for controlled substances—and if the physician is aware of it, that physician is in knowledge of a felony. As such, the physician is obligated to report it.2 However, as soon as the crime is reported, the physician faces a great deal of time in court as a witness, as well as the ire of his colleagues who also find themselves in court because of their unwitting participation in a drug seeker's efforts to illegally obtain and use narcotics. Failing to report a felony is a crime that could get physicians relieved of their licenses and subject them to criminal penalties.3
Physicians also face the dilemma of wanting to help legitimate pain sufferers without having the ability to determine who is lying and who is telling the truth about their pain. I have found myself having to explain my "harsher" approach to patients who wonder why, after years of using acetaminophen/oxycodone (Percocet), they now must see pain-management specialists. I tell them that, as in junior high school, a few misbehaving individuals cause everyone to pay a price. I no longer prescribe any scheduled or controlled medications without a demonstrable fracture or history of cancer, unless I first consult a pain-management expert.
There are many nonnarcotic options available for patients, but the protests are legion when I suggest them. I have been verbally assaulted by a patient in the emergency department for not prescribing a narcotic to that individual, who had failed to keep a pain-management referral and who had been seen at several other emergency departments. I have also been confronted by a patient who I initially thought had legitimate pain complaints but whose subsequent urinalysis indicated the presence of tetrahydrocannabinol, the active compound in marijuana, but not the presence of opiates—despite the fact that the patient had been using oxycodone hydrochloride (OxyContin) for years under the care of another physician. He tried to explain these findings by pleading, "You understand, doc, I just smoked some pot. Come on, doc. It was just pot!"
I replied, "No, I do not understand. I spent a year away from my wife and kids, lost three friends between Iraq and Afghanistan, and had a young man I have known since he was a baby lose his leg to an IED [improvised explosive device]. I am drug tested yearly, and I have never used drugs. No, frankly I do not understand. By the way, where is your OxyContin going if it isn't in your urine"
Examples such as this kind can further jade a physician against future prescribing, even in the face of seemingly legitimate pain.
The United States has poured billions of dollars into an international "drug war," while it has virtually ignored the fight at home. Every day in this country, drug dealers, users, and traffickers show up in physicians' offices, playing against physicians' sympathies and our legal mandate to address patient pain in a timely and appropriate manner. These criminals take their prescription medications (many of which are paid for by state Medicaid programs for the poor) and walk out to sell them for cash,4 as some of my own patients have admitted to me. The only difference between these cases and instances in which the Medellin drug cartel pumps our kids full of cocaine is that the former cases are conducted under the guise of medical legitimacy.
Data for retail and mail-order pharmaceuticals reveal that acetaminophen/hydrocodone (Vicodin), which is a narcotic pain reliever, is now the numberone prescribed drug in the United States, with atorvastatin calcium (Lipitor), a medication used to lower elevated cholesterol levels, running second.5 In my area of the country, Vicodin sells for about $10 a tablet on the street, according to some of my patients.
The most serious problems occur when addicts show up at clinics and demand specific drugs under threat of harm to nurses or physicians. Such threats have happened to some of my colleagues. I did not spend the better part of my youth in school to face threats from drug addicts. It is truly enough to cause a person—and it has caused me—to start looking at other ways of making a living.
There is a solution to this problem, but like many solutions, the implementation of it after years of neglect will not be easy or pleasant. I offer the following four suggestions.
First, the federal government must mandate that computer systems link all pharmacies that dispense controlled substances. When a patient solicits the same medication from several different pharmacies, the pharmacist is immediately alerted as soon as the prescription information is entered. Pharmacists should then be required to report this data to law enforcement authorities.
The federal government should also mandate—just as it has with HIPAA—that practitioners who prescribe controlled substances comply with a federal standard for tracking the use and effectiveness of those substances. These records should be clear and comprehensive so that when the Drug Enforcement Administration needs to investigate alleged abuse, it can readily form a paper trail to prosecute drug abusers.
In addition, federal programs such as Medicaid and Medicare must mandate that each recipient of federal assistance for medical care has an assigned family physician. I know from personal experience that many patients seen in emergency departments have no family physician. Therefore, it is fairly easy for them to go from one emergency department to the next, collecting drugs without being caught. Currently, there is little or no surveillance of Medicaid patients using emergency departments as their sole source of medical care. I have seen certain Medicaid patients use the emergency department as many as 23 times in one month for minor health problems, and nobody from social services ever called to inquire why. This is not only terribly abusive of the taxpayers, whose money is used to help people in need, but it is a huge drain on federal resources that are needed to care for the truly needy and the growing elderly population.
Finally, the pharmaceutical companies that manufacture medications for chronic pain must be challenged to produce more medications like morphine sulfate (Avinza),6 which is a time-released opiate sold in capsule form. Avinza is excellent for severe pain but produces no "rush" or euphoria like OxyContin tablets; therefore, it has no street value. By contrast, the current street value of OxyContin is about $1 per milligram, and a prescription for OxyContin (40 mg) taken twice daily for a month is worth $2400.4 In general, capsule medications are less valuable than tablet medications, because tablets are easier to divide, "cut," or otherwise tamper with than capsules, leading potential buyers to have doubts about the drug's safety and efficacy.
I believe that the abuse of prescription medications by patients has reached the level of a national crisis, resulting in wrecked lives, neglected children, violent crime, injured police officers, and deaths of addicts. This crisis also affects every patient in the country—as one of my own patients found out recently, when after years of caring for her for arthritis, I told her I now had to refer her to a pain-management expert. I explained, "I do not have a pain meter in my head, and I can't tell who is or is not telling me the truth [about their need for pain medication]."
The longer the United States delays in establishing strict criteria and digital monitoring of the use of pain medications, the more likely it is that the average person in need of such medication for pain control will be confronted by physicians who refuse to prescribe without a consultation. This situation does not help patients in need of care and it causes grief for those of us who have made the care of the suffering our profession.
However, there is one alternative. It is terribly unpalatable, but if the United States refuses to treat the drug problem as a true national crisis, then the only option, in my opinion, is the full legalization of narcotics. I have struggled with this conclusion, but I believe that making these drugs legal would lower their value through market pressures, removing the financial incentive for the people involved in making and moving these substances. I shudder at this thought, but it is the sad truth and one that, after serving my country in Iraq, I wish I did not have to return home to.
Footnotes
As the premier scholarly publication of the osteopathic medical profession, JAOA—The Journal of the American Osteopathic Association encourages osteopathic physicians, faculty members and students at osteopathic medical colleges, and others within the healthcare professions to submit comments related to articles published in JAOA and the mission of the osteopathic medical profession. The JAOA's editors are particularly interested in letters that discuss recently published original research.
Letters to the editor are considered for publication in JAOA with the understanding that they have not been published elsewhere and that they are not simultaneously under consideration by any other publication.
All accepted letters to the editor are subject to copyediting. Letter writers may be asked to provide JAOA staff with photocopies of referenced material so that the references themselves and statements cited may be verified.
Readers are encouraged to prepare letters electronically in Microsoft Word (.doc) or in plain (.txt) or rich text (.rtf) format. The JAOA prefers that letters be e-mailed to jaoa@osteopathic.org. Mailed letters should also be sent electronically, in one of the aforementioned electronic formats on an IBM-compatible CD or a 3-inch disk, and addressed to Gilbert E. D'Alonzo, Jr, DO, Editor in Chief, American Osteopathic Association, 142 E Ontario St, Chicago, IL 60611-2864.
Letter writers must include their full professional titles and affiliations, complete preferred mailing addresses, day and evening telephone numbers, fax numbers, and preferred e-mail addresses. Authors are responsible for disclosing financial associations and other conflicts of interest.
Although JAOA cannot acknowledge the receipt of letters, a JAOA staff member will notify writers whose letters have been accepted for publication. Mailed submissions and supporting materials will not be returned unless authors provide self-addressed, stamped envelopes with their submissions.
All osteopathic physicians who have letters published in JAOA receive continuing medical education (CME) credit for their contributions. Writers of original letters receive 5 hours of AOA Category 1-B CME credit. Authors of published articles who respond to letters about their research receive 3 hours of Category 1-B CME credit for their responses.
Although JAOA welcomes letters to the editor, readers should be aware that these contributions have a lower publication priority than other submissions. As a consequence, letters are published only when space allows.
References
6. Avinza (Ligand). RxList Inc Web site. December 8,2004 . Available at: http://www.rxlist.com/cgi/generic/avinza.htm. Accessed October 6, 2005.(Todd Fredricks, DO)