Until the government stops treating emergency physicians as the scapegoat for opiate addiction, we won’t be able to address the real issues facing this challenging patient population.
The comments section of Yahoo News is a great resource to gauge the pulse of the common man. Now that Ms. Clinton has taken up the battle cry against Heroin abuse and deaths in our nation, Americans are speaking out. Physicians are being blamed for introducing pain patients to Hydrocodone and Oxycodone, after which they become addicted. When their supply is cut off by their provider, they turn to the streets. Soon they find the only drug that satisfies, and often that is heroin.
The common man has blamed physicians for the making of this crisis. The FSMB, the Medical Boards, and DEA have reacted by hog tying prescription writing of opiates. This particularly impacts the practice of emergency medicine. The Virginia Supreme Court has allowed patients to sue their physicians for malpractice for addicting them to opiates. I submit that those patients were addicts before they discovered opiates. Opiates are just a medication of convenience, and when their source dries up heroin becomes an alternative.
Our Governing bodies have made us the cause rather than the cure. This should be very alarming. We cannot screen for the propensity for addiction, and even addicts need to have acute and chronic pain managed. I would argue that a loosening of narcotic regulations rather than a tightening of them is required to reduce heroin-related injuries. The Government also needs to look at its own organizations and contractors. Why did the heroin in the US before the invasion of Afghanistan represent only five percent of the total from that country, and after it jumped to eighty percent?
We also need to be concerned about the cost of Naloxone. When pre-prepared autoinjectors of Naloxone are $360 for two, we need to question whether it is priced meaningfully for use by addicts and their kin. We cannot provide a safety net when the net is priced beyond the reach of the target consumer.
As emergency physicians we are the experts in acute pain management. It is time we address the issue to our respective governing bodies, and help them to understand that we did not create the heroin crisis. Neither did we cause the pain that led to opiate abuse. We are here to treat it, to help, and in the end to cure not only the injury and ills of our patients, but the society as a whole.
One large issue not mentioned in this article is that of Press Gainey patient satisfaction scores and hospital administrators pressuring ED physicians to increase their scores by any means necessary, in order to keep their jobs. I live in Kentucky 2 miles from the Virginia state line and 60 miles from the West Virginia line. I am licensed in all three states. In 2012 Kentucky passed a law requiring all providers to query the state database before prescribing controlled substances, and otherwise severely limiting the prescribing of controlled substances, particularly in emergency departments. The result in Kentucky has been the ending of pressures on us to prescribe inappropriately in order to keep our jobs. The result for me personally is that since 2012 I have limited my practice to Kentucky.
Imagine if Wal Mart or Target included those arrested for shoplifting and other known criminals in their customer satisfaction surveys, and paid great attention to such responses. Only our profession is subject to such nonsense.
There are emergency physicians practicing which are very generous with narcotics, for example treating tooth pain with dilaudid injections, and narcotic prescriptions to go in an attempt to avoid complaints which would get them terminated. Until we disconnect satisfaction scores from narcotic prescriptions, this abuse will continue, and EP’s seem to be in the firing line. Or, EP’s will have to get more conservative with their prescribing practices and deal with the consequences.
I certainly agree with Drs. Hardman and McIntyre regarding the pressure applied by hospital administrators. It is a lose-lose situation because they are pressuring the emergency physicians to do “whatever necessary” to make sure those Press-Ganey scores are high (i.e., prescribe whatever you need to to keep the “customer” happy) but at the same time expressing “dismay” at the amount of narcotics being dispensed from the EDs. Another thing that is rarely mentioned is that there is virtually no support from many heads of large emergency groups because they don’t want to jeopardize their hospital contracts.
As a practicing emergency physician (recently retired), I never prescribed more than 8 – 10 Tylenol #3’s or hydrocodone 5 mg’s for a patient – and that was almost always based on physical evidence of disease or injury. However, I occasionally saw patients that had been seen by some of my colleagues who had recently prescribed 30 or more tablets for someone that should have followed up within a day or two with another physician. I guess we all have different ideas about what constitutes a “few” pills.