Since the emergence of COVID, opioid abuse and the issue of treatment of pain vs. illegal use and addiction has taken a back seat in the crisis and panic train. Depression, overdose, more addiction has been the result of our lockdowns, job losses and unreasonable restrictions on recreation and free movement. I am sure once the statistics come forth we will learn of the impact COVID has had on the “opioid crisis”
I had a bad crash a few years back while skiing some pretty steep chutes. I had done the route many times but got sloppy and fell upward and then back against terra-firma. I could barely get up and stand. My low back and hips were on fire and typical of a male, I skied down, told my buddy I was done and hobbled back to my car. What came next was revealing. I arrived at the Hospital Emergency Department, could barely stand, let alone walk to the doors. Wheelchair please? Not. After I checked in and they called me back, wheelchair please? Not. Now I’m not a baby, but seriously, I can barely walk at this point. I have been in the business for over 40 years and would never have allowed this in my clinics. The nurse was great, got me finally in a wheelchair back to the x-ray department and the Doc who looked like a teenager came back smiling and told me “good news, your hips are in great shape, no replacements for you”. Ok, so did I break my freaking back? No. Ok, so what now? I had to drive myself back to my home where I spent the rest of the next few days mostly in bed. No fractures. What’s missing in this story? You guessed it. No pain medication during the visit or prescribed after I left. Nothing. No Norco, no Oxycodone, no Tramadol, not even tylenol #3 or a leather strap to bite down on.
Now I’m a pretty tough guy, not a crybaby but I was hurting. It would have been nice to have a few pain pills for a few days. Back only 10 or so years ago, pain was considered another vital sign. Right up there with pulse, blood pressure, respiratory rate. We were actually rated on patient satisfaction with how pain was treated. Now if we prescribe narcotic pain meds we are monitored for “proper” use by everyone including our employers, state, county and any official that holds a license over us.
I was working late in my Urgent Care and a fellow came in complaining of “dental pain” Now mind you I have nice teeth and see my dentist regularly but I am not a dentist. Red Flag. I strap on my compassion helmet and do my best not to pre-judge him as a drug seeker but after some homework by my crew and some phone calls we find the gentleman to be holding 3 separate IDs and I was the third stop in his effort to obtain narcotics. I played along, saw the Patient and recommended Tylenol and Aleve and wrote for an antibiotic for possible tooth abscess. I thought he was going to go Postal, and try to assault me when I told him no narcotics and explained I knew he had been elsewhere and was denied. I offered to call the Police to escort him out and that persuaded him to leave. So, thoughtfully doing my due diligence, I call the Police, let them know about this guy and they could care less. So I call pharmacy and they also are impotent. No one goes after these folks. Now you may think this is the end of this paragraph but not so. Following the episode I am confronted by certain practitioners in my own group who tell me I am too conservative when it comes to prescribing narcotics for pain. Hmmm. Surely.
Every two-year cycle for my medical license we are required to get continuing education credits and some of those must contain narcotic prescribing and opioid education. I dutifully attend and hope for at least some sandwiches, so I sit near the aisle at the back. The education for the most part is ok, includes “experts” and law enforcement folks. But these classes are a formality forced upon us so the powers that be can claim they are doing something about the “crisis”.
And they certainly are. They reprimand those that have poor record keeping, have locked up some Doctors that actually were criminals. But in the process, pain goes undertreated and sometimes completely ignored for fear of reprisals.
The Hot Potato
No one wants to take on opioid prescribing for their patients these days. It requires pages of documents and contracts and worry that you will be scrutinized by the Medical and Pharmacy Boards. The hospitals might give a half dozen pills after a surgery but the surgeon sidesteps this….Really? I just had my guts opened up and no pain meds? I just crashed hard while skiing and can barely walk and no pain pills? Call your primary care provider for assistance. If you need ongoing pain medication you are referred to a “pain specialist” Next available appointment in 2 months. But I hurt today!
So I get a call from a hospital Doc about a patient I just met once. She is in her 80s, has a history of back fractures, chronic pain and has been on narcotic pain meds for many years. The Patient went into the hospital for urinary tract infection, but the Doctor felt it necessary to lecture me about writing for narcotic pain meds for this patient. She was accusing me of being a criminal. She claimed the patient was in narcotic withdrawal. Funny thing is, while in the hospital they: Injected her with a narcotic many times more powerful than her pills from home. They sent her home with no additional pain meds (this is assuming she had run out at home). And come to find out her Son, who is “managing” her meds is an addict and likely siphoned off her meds for himself. Did this Doctor consider any of these facts? No. Did this doctor refer to pain management? No. The Hot Potato. Easy to criticize others, but not to act on behalf of the patient. It felt good to get in a few choice comments during our conversation. She was also completely unaware that at my first meeting with this lady, I had already begun a taper down from the previous Practitioner’s dosing regimen of opioid.
Ultimately it is the patient that loses out in this scenario. She has chronic pain and will likely always need management unless we can create a new pain free body for her. Chronic pain is a whole different animal compared to when I crashed and hurt my back skiing. I cannot trust to give her opioids for her to use in her home any longer due to her family/social situation. It’s just not safe. (Did I mention she is also somewhat demented?) By state mandate I am required to provide for 30 days of her medications which I will do so gladly, but have to discharge her from my care. I have to protect my career, license and peace of mind. Did my bosses agree with this? No Steve you can’t do that. Yes, I can and I will, sorry, but I have to sleep at night also.