The 'Opiate' Crisis Reimagined: Medical Drug Lord or Community Saint?
Disclaimer: The views herein are my own and do not represent any institution and do not qualify as any medical advice. You’re reading the blog of a third-year medical student so I hope the previous sentence is common sense.
My internal medicine rotation thus far has been interesting, and I have had a compassionate preceptor who has a unique patient population. After the first few days, my initial perception was that my preceptor was a medical drug lord. He has some patients that give you an unsettled feeling like there may be some drug seeking behavior, or a previous history of drug abuse perceived by the various forms of meth face I have seen. After hearing the former HHS speaker Tom Price at an event in Atlanta, I was already familiar with the HHS agenda toward the ‘Opiate Crisis’. So, I took special note of all the narcotic medications being prescribed to patients. Even previous students had warned me that my attending gives narcotics out “like candy”, but my perspective was drastically different from what preceding students had me believe.
His patients love him. It is easy to write this off to the fact that maybe you’d love your prescription dealer too, but that is not the case with this doctor. He does not wear this cloak of compassion when you meet him; your initial impression is skewed based on his cultural differences and seemingly abrupt personality. After attentively listening to what he has to say, and listening to his approach to managing patient care, I realized one day that he is one of the best patient-centered providers I have met. He knows everyone’s story. Every patient of his was like a part of his own personal family in terms of how he spoke about them. He knew who had went through what divorce in what year, knew about their accidents, cancer treatment history, successes of the patient’s children, and many aspects of the patient’s career and home life. I am not saying he documents this electronically, looks it up before seeing a patient, and then is reminded of the patient’s story.
No. He can see the name written down on the paper patient list for the day, and start telling you the patient’s story as though it were his own. It was incredulous the amount of material stored in this man’s mind. He genuinely was invested in the lives of his patients, and his goal in treatment has been to improve the patient’s quality of life. He helps patients manage their pain through pharmacologic and nonpharmacological means. With the recent discussions of ‘opiate crisis’ in the news and the anxiety that has brought his patients, he has started to shift how he cares for his patients. It is not difficult to discern his mistrust of politics or in the government’s imposition of practice-changing legislation (although again, some of that may be due to his cultural background and deserving mistrust of government).
Being my chipper and curious self, one day I asked him about his views of the ‘opiate crisis’ and what he thinks about the direction pain management is heading in our country. He began by describing to me how new this ‘crisis’ is and how America’s opiate addiction is a government-derived problem in the first place. He relayed how in the 90’s there was this shift in healthcare toward asking for the sixth vital sign: pain scale. He told me that this subjective measure being added to an objective portion of the exam was ridiculous, but since it was a quality measure for reimbursements that physicians altered their practice to comply with what the government is legislating. I had already heard this from former speaker Tom Price’s speech, but it had more bearing the way my preceptor described the prescribing shift (probably because my attending did not have to watch what he said since this wasn’t a political game but a private conversation). I did not realize how powerful Medicare/Medicaid policy really was in altering how medicine is practiced. Since this inclusion of this new vital, physicians had a goal to work with the patients toward lowering pain which led to writing prescriptions for opiates as though they were they new ibuprofen. He even described to me how back then you could call in opiate medications to the pharmacy, which was mind boggling to me, but many opiates where not classified from schedule III to schedule II until 2014 (Schedule II meaning they need a written prescription delivered in person by the patient). So, if a patient had reported a certain level of pain on the pain scale then it needed to be addressed in the patient encounter.
And then there’s his story of the “secret shopper” that blew my mind. He told me a story of how a federal agent came to his practice with drug-seeking behavior under the guise of a being new patient. After denying the ‘patient’ an opiate prescription, the doctor’s files were subpoenaed for investigation after claims that he over-prescribes opiates. Nothing was found on investigation, and he was cleared to continue practicing as he had been. Wow. So, not only is government able to say how a doctor should practices, but they send spies into practices to police doctors? I in no way mean to imply that doctors are without reproach and I advocate for checks and balances in all aspects where patient safety is a concern. However, creating a sting operation like you would for a pedophile or someone who pays for the services of a prostitute is a little degrading to the medical profession. Anyway, my attending was cleared as he had no foul play.
Why? This doctor really is genuine with his patients and does not have much tolerance for deviated behavior. If a patient even suggests to him that there may be some drug-seeking behavior, then the doctor informs the patient that he will need to see a pain management specialist (a doctor who has completed a fellowship or additional training in pain management) and that the doctor will no longer be able to prescribe opiate medications. For some patients, he has implemented a cut back regimen. Pain patients already have to come in once a month for opiate prescriptions due to the schedule restrictions, but this helps with cutting back pain medications.
Some of the changes my attending has put in place:
He stopped taking new patients who had a chief complaint of pain.
New patients with new onset pain either need to go to an acute care setting, or try non-pharmacologic and over-the-counter approaches first.
He has been referring patients out to pain management specialists which increases the burden of those practice settings.
Patients with atypical behaviors/inconsistent adherence to treatment are informed to find a new provider and given a 60-day notice that treatment will stop. He even goes as far to provide a list of other providers out of ethical obligation, but his responsibility to the patient does not extend past a 30-day notice according to Georgia laws.
Patients are decreased each month by 5-10 pills if they do not have a terminal illness.
Has been openly sharing information from governmental changes with patients to plant the seed of switching to non-opiate medications.
Let me step back: these patients aren’t in pain because they pulled a muscle or something trivial requiring a short course of muscle relaxers and NSAIDs. Many of these patients have terminal cancers that have metastasized or are unresectable/treatable. Some of these patients have rheumatoid arthritis that has caused some of the most severe hand deformities and these patients are legitimately in pain. I have met diabetic patients with neuropathic pain refractory to many, many non-opiate pharmacologic treatments. I have met patients who have had some of the most bizarre injuries like falling off a roof, being hit by a car while biking, car accidents, work injuries involving large machines, falling out of a window, jumping out of a window, being pushed out of a window, multiple gunshot injuries, and knife injuries. Some of his patients have been treated pharmacologically for pain with opiates for 10 to 20 years. He has helped his patient find some type of quality in their day-to-day lives by managing the pain. You can imagine how difficult or frustrating it can be for the physician to change practice management after 20+ years due to the governmental approach to opiate treatment compounded with litigious fear if the patient is not properly weaned off of opiates and changed to a different treatment approach.
My impression is that he is providing the community a service, and is doing so in a systematic approach customized to the individual patient. He sees patients many providers would not feel comfortable seeing, and is willing to prescribe them opiates based on their clinical picture. Many patients will tell you how they were denied pain medications by their oncologist or their rheumatologist, but he at least will continue the care provided initially at some of these practices or will modify the treatment regimen based on what the patient needs. Could you imagine having cancer that has metastasized to your bones and has a poor 5-year survival prognosis? And more, if you were being denied opiate medication because the fear you will overdose outweighted the need for pain treatment? It seems unethical, and much of what we do in medicine is about the balance between benefit of treatment versus the risk of harm. I do not think the scales should be tipped because of our medico-legal environment trumping the clinical picture of the patient. I am also still very naïve in medicine with very much to learn, but I am thankful to have this attending show me what it is like to put the patient's needs ahead of the fear of repercussion. He very much professes if you are doing the right thing for your patient with consistency then you should not be afraid of government.
For the small percentage that might be drug seekers, they are getting medical care every month. I’m not trying to justify the drug abuse, but addiction is a mental health disorder that requires an intensive approach if you are going to help these patients achieve long term abstinence. Instead of being on the streets seeking heroin (which also attributes to opiate deaths as heroin is an opiate and would test positive as such but I speculate it is not the focus due to how difficult this would be to regulate…), these patients are able to see a doctor and have their health monitored. Again, I am not encouraging drug addiction or abuse, as these are serious issues that need to be addressed in our country and by our government.
Furthermore, I do not think our legislators have a good idea of what it is like based on this minimalized approach targeting prescribers. If our focus was on mental health needs of the citizens coupled with funding for addiction services and research, then maybe we can work toward fighting drug addiction and abuse in our country. Prescribers should be educated to the dangers of opiate abuse and overdose without a doubt. But, the danger lies in the use of government tries to be the doctor. Even more, maybe patients would seek treatment if there was a change in the stigmata associated with drug abuse or there was not a fear of legal repercussion. Other countries have been more successful with the approach to addiction and treatment so maybe it’s time we open up to collaboration and learn something from our counterparts with better statistics. Opiates have been used by humans for thousands of years, and it has been speculated that asking if addiction or pain management came first is like asking the chicken or the egg. So, I imagine that we will have many years to go in finding the balance between addiction and adjunctive therapy in modern medicine.