I don’t know what’s going on with American College of Emergency Physicians (ACEP) lately, but it’s disheartening. Their abdication of responsibility and engagement during the healthcare reform debate was depressing. Then there was a rigged poll designed to elicit a predetermined result. Now I see a bizarre op-ed piece in USA Today entitled “Opposing view on drug addiction: Don’t make us ‘pain police’” and authored by ACEP President Angela Gardener. An excerpt:
The patient-physician relationship is sacrosanct, demanding candor and trust. In the emergency department, trust is built in nanoseconds because patients and doctors do not have prior relationships. Knowing that any pain prescription will be entered into a large, public database might prevent patients from being truthful, or in the worst case, from seeking needed care. … As an emergency physician, I can assure you that the drug abusers who use the emergency room simply to get a prescription drug fix represent a micropopulation of the 120 million patients who seek emergency care every year in the USA. … Put bluntly, if legislators have money to spend, they should spend it where it will do the most good for our patients, and that is not on drug databases.
I really don’t know what to say, other than to wonder whether Dr. Gardner and I practice in the same United States in which abuse of prescription drugs is growing exponentially and in which “drug-seeking” patients are a part of each and every shift worked in the ER, where deaths due to overdoses of prescription medications are on the rise, and where diversion of narcotics is a serious and growing problem.
Dr Gardner is correct when she writes that drug seekers are a “micropopulation” of ER patients. But that’s a meaningless measure of the problem. Acute myocardial infarctions are also a “micropopulation,” as are hip fractures, asthmatics, and most every other complaint you choose to split out from the nation’s ER census. (Indeed, in many ERs, low back pain is the #1 discharge diagnosis.)
To minimize the problem, to dismiss it as a “micropopulation,” is to willfully turn a blind eye to the disease and its human cost. And make no mistake — addiction to prescription medication ruins lives and kills people.
I vividly remember the tragic case of Debra. A combat veteran, she had been thrown out of the Navy after acquiring a chronic painful condition which had been poorly managed, leading to dependence on opiates and sedatives. Dependence turned into addiction and I saw her numerous times over a two year period. In some cases she was looking for refills, in some she complained of pain exacerbations, and in some she was unresponsive after overdoses.
It was a real challenge figuring out who was supplying her with meds (she had dozens of doctors), and in the end she was reduced to taking veterinary sedatives ordered from Mexico. I spent a lot of time trying to get her into treatment, without success.
One day I saw her name on the list of patients to be seen. I sighed and went into the room and was shocked — it was the same patient, but a very different person. She had a tracheostomy tube and was on a ventilator. There was a tube in her stomach for nutrition and one in her bladder for elimination. Her mother, with a sad look, sat by her bedside. (No family members had ever accompanied her to the ER before.) She explained that a couple of months prior, Debra had overdosed again, but this time she had stopped breathing and had suffered an anoxic brain injury, leaving her in a permanent vegetative state.
I’m sure that Dr Gardner knows this, but it bears emphasis — drug addiction kills. We ER docs are on the front lines of this and so many other social challenges. We need all the tools available to combat these problems. I agree that it would be onerous to be required to check a database every time I wrote for a controlled substance. That should be changed. But if it’s possible to compile the data, give it to us and let us use it as needed when we have concerns.
Trust needs to be established between the doctor and patient, and in some cases the maxim “trust but verify” is appropriate. If I have concerns that a patient isn’t being honest with me, if I have concerns that their story doesn’t sound quite right, information is an important tool to open up the discussion and maybe prevent further tragedies, or at least reduce the role of the ER physician as an unwitting enabler of ongoing drug abuse.
It’s depressing to see the leaders of our specialty opposing such common-sense measures to improve patient safety and enhance our ability to deliver appropriate care.
*This blog post was originally published at Movin' Meat*