When to give pills to a drug seeker

I saw a 31 year-old in the ED last week who came in complaining of wrist pain after falling from his skateboard. The triage nurse did not find his story compelling (acute) enough for immediate transfer back to the ED. He was upset then told the nurse that he also had abdominal pain as well.

Once in a room back in the ED I looked at his hand. There was not the least sign of a fall: no abrasion, no redness, no swelling, no deformities, no numbness, no cold hand, no painful movement. When I pressed on his hand bones he vaguely retracted his arm as if to show me that he was in pain. He made no facial grimace when I asked him to gasp my fingers as hard as he could. It was pathetic acting. People really in pain wince when you push in a tender place or ask them to use a part that hurts. They do not look at you stone-faced. They do not invite you mash around on a sore body part, as this guy seemed to do, with "push there, it really hurts, yeah, right there, and it hurts here too, push there."

As part of a routine exam I asked him if he had any underlying medical conditions. He leaned forward and said in a suspicious voice, "this is just between me and you - you can't tell anyone - but I have 4 herniated disks in my back and so I take a lot of Percosets. You see, I need a lot more pills than usual to help my pain." Percoset is one of the many prescription pain pills. It is a narcotic, a relative of morphine, opium, and herion. He gave me some bogus excuse for this secrecy as needing to protect his health information from his insurance company, which would drop him if it discovered he had an expensive medical condition like 4 herniated disks. The story was absurd, obviously. Having such a debilitating back condition like that at such a young age would be a perfectly good reason to have insurance. And why the hell was he riding a skateboard anyway? And why was he telling me medically relevant information if he didn't want it in his medical record?

As I stood up to leave the room I excused myself by saying that I would discuss the case with my supervising physician, as I always say to every patient. He jumped up from the exam table and closed the door in front of me. "You promised you would not tell anyone, who are you going to tell now?" he exclaimed somewhat desperately. I brushed him aside and immediately left the room. This was clearly a sign of aggression.

If there was ever a "slam-dunk" case of a drug-seeking patient, this was him. I have no doubt that this guy made up story of falling on to his wrist as an excuse to get narcotics from the ED. Every ED doc in a urban center will see someone like this on every shift. It is aggravatingly common. I offered ibuprofen and ice, which is exactly what I would have given my own friend or child, but he insisted that his pain was just too bad that he needed something more.

What makes treating pain so tough is that one can never know how much pain a patient is in. Sure, clinical experience gets you a long way, but ultimately it is based on the patient's report, and even then one and the same type of condition may very well be more painful to one person than another. However this case was straight-forward, and it I admit I content to know confidently that his claim of pain was false and his visit to the ED was a ploy to get drugs. A young healthy guy falling off his skateboard with absolutely no evidence of injury (wrist x ray was negative) will not be the sort of pain that warrants narcotics.

There are many ED docs who would have just given him a few days of pills and sent him home. That's the easy way. You get the patient out of your ED and free up your bed for someone else. No arguing with the patient, no explaining why you are "so mean and heartless" for not understanding what the patient says they are going through.

In reality, most cases of pain management in the ED are not so black and white. Many involve people with chronic pain conditions (back pain is classic), who really do have pain and really do need pain relief, but have become dependent on narcotics. And the dependence is not only physical. Actually the psychological dependence is perhaps more common and destructive. So many people I see on chronic narcotics have come to refashion their identity around their disability and see narcotic use as the one way they can be functional. It is a rationalization, just as with any drug abuse behavior. Ironically people on long-term narcotics are notoriously non-functional. The pills dumb you down, they're sedating. Sure, they make you don't care about your pain, but they also make it less likely for you address that pain in a positive way. Motivated people with chronic back pain are usually able to manage it with changes to their lifestyle, such as loosing weight and exercise. But pills, as our culture has increasingly come to believe, are the easy answer.

It behooves me to develop my own personal policy about narcotics since I will be working in the ED. I think the Japanese have a great approach. In Japan prescriptions for narcotics are illegal except in a few cases or known, documented chronic pain, such as cancer. This makes a hell of a lot of sense. In the hospital or clinic the patient is there under your supervision. They are not going to over dose or abuse the medication. They are not going to sell it on the street. I think liberal use of narcotics when indicated while in the ED is totally justified. But sending home people with narcotics who do not have a convincing reason for needing them, I think, is bordering on unethical. Sending this guy home with just 3 days worth of pain pills - say 20 - can fetch $200 on the street. That's not bad money from sitting in the ED for 3 hours.

There are now more deaths from prescription narcotics (Vicodin, oxycodone, codeine, Percoset, Dilaudid) that from street narcotics (heroin, opium). By following our Hippocratic oath to do everything in our power for the "good of the patient" we have inadvertently created a epidemic of physician-mediated narcotic abuse. Getting these millions of people of these meds will be a huge challenge to come. Especially since the association of chronic narcotic use and mental illness, such as depression, is alarmingly, if not surprisingly, strong.

An even larger challenge will be reversing the cultural attitude in this country that one is entitled to live free of pain. We need to look to other cultures and to our own ancestors who suffer and suffered from just as much pain as we do and yet did not dependend on narcotics. Pain is very much moderated by emotion and context and how much significance one bestows on it. It is a fact of life, of aging, of disease. It hurts and it's inconvenient, but perhaps in the greater scheme of things there's a reason for that: pain forces us to be aware of our bodies' frailty and vulnerability.

Seven Reasons Why Americans Spend a Crap Load on Health Care

In the June 18 issue of the Journal of the American Medical Association there is a nice opinion piece that summarizes some key points about why health care is so expensive and ineffective in the US compared to other industrialized nations. Check out the stats in the table above.

In brief there are 7 points why health care is so expensive in the US:

1. A physician culture that privileges meticulousness over effectiveness.
   The Hippocratic oath, ingrained in every doctor and medical education system, values thoroughness of medical investigation regardless of cost. I am trained to order as many tests as necessary to eliminate every diagnosis possible, regardless of how likely they are. A patient with a "slam-dunk" bedside diagnosis of appendicitis will still get a $1500 CT scan in most hospitals to confirm what what was already known.
   
2. Fee-for-service system that provides economic incentive for providing care.
   As long as doctors have practices that are run like businesses (most are) this will always present a potential conflict of interest. In reality many doctors rationalize care that may not be necessary by the above principle of "meticulousness." Doctors need to be compensated for results not just for providing care. A very good article in the New York Times on CT angiograms is an excellent example. Economic incentive further hurts our system by irrationally over-compensating procedures compared to non-procedural cognitive aspects of medicine, resulting in a flood of doctors toward specialties and a brain drain away from primary care.
   
3. Pharmaceutical & medical device marketing to physicians.
   The medical world is awash in information that is impossible even for the most recluse speed reader of medical journals. Anything that gives busy doctors a summary or this information and how it may change their practices is very attractive, and this is precisely the role that marketing reps from the industry fill. The problem is that this information is crafted to buoy sales.
   
4. Fear of being sued.
   There is some debate over how much malpractice lawsuits actually increase health care costs. Doctors point to this as a major factor, but it is likely exaggerated. Nevertheless, I see doctors making "cover my ass" decisions to do a test all the time. And these are rarely for the patient's benefit, although many patients think they're getting better care, and they always add more costs.
   
5. Patient preference for new fangled technology regardless of proven efficacy.
   Americans are addicted to technology, especially when it presents an easy way - or the illusion of one - to solve a problem that is really behavioral or cultural in nature. My favorite example is narcotic pain pills for chronic pain. And doctors feed this desire with enthusiasm. It is a pathetic co-dependent relationship.
   
6. Direct-to-consumer marketing.
   The drug industry has been very successful at convincing people that if anything stands in the way between their right to total joyous bliss every second of their lives then there is a pill. Aging has become a disease. Suffering has become a disease. Not getting a hard on and the snap of one's fingers, has also become a disease. It is becoming commonplace that the patient comes to the doctor asking for a drug for a problem they think they have because of a commercial.
   
7. Shielding the true cost of care from patients.
   Few people understand what anything really costs in medicine, including doctors. When it comes to our health our attitude is, like the Mastercard commerical, "priceless." Over fifty percent of the health care resources a typical patient consumes is in the last 1-2 years of life. That's a whole lot of money spent on keeping very sick, frail people on the cusp of death from dying. Personally, I think a lot of this has to do with our Christian values, which have been perverted by contemporary politics, selfishness of the aging babyboomer generation, and over-confidence in medicine. We have a very poor understanding of death as a culture. We don't accept it, much like our attitude towards debt (thanks again to Mastercard). The thinking from "life is sacrosanct" easily leads to "life at all costs" and then to "death is a failure of morality."
   

Pediatric Vital Signs

Pediatric Vital Signs

Typical vital signs in the pediatric population

Extracted from: Jorden RC: "Multiple Trauma" in Emergency Medicine - Concepts and Clinical Practice 3rd ed.; Rosen P, Barkin R et al. (eds). 1982 Mosby-Year Book, Inc. p281-282

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AGE WEIGHT (Kg) PULSE RESP SYST BP DIAST BP Premature 1 145 <> 42 +/- 10 21 +/- 8 Premature 1-2 135 50 +/- 10 28 +/- 8 Newborn 2-3 125 60 +/- 10 37 +/- 8 1 mo 4 120 24-35 80 +/- 16 46 +/- 16 6 mo 7 130 89 +/- 29 60 +/- 10 1 yr 10 120 20-30 96 +/- 30 66 +/- 25 2-3 yr 12-14 115 99 +/- 25 64 +/- 25 4-5 yr 16-18 100 99 +/- 20 65 +/- 20 6-9 yr 20-26 100 12-25 100 +/- 20 65 +/- 15 10-12 yr 32-42 75 112 +/- 20 68 +/- 15 Over 14 yr > 50 70 12-18 120 +/- 20 75 +/- 15

Evil in South Dakota: State Forces MDs to Lie.

South Dakota's unbelievable new abortion law. - By Emily Bazelon - Slate Magazine

Satan is alive and kicking in South Dakota, if you use deception, lies and trickery as a marker of evil - as I would. Doctors providing abortions in SD will soon be forced by the state to say things they know to be false, like "the fetus you are carrying is an unique, separate human being" and just downright misleading like describing adverse effects of abortions like "increased risk of psychiatric stress and suicidal thinking."

First the "unique, separate human being" part. A fetus is a sort of parasite. The fetus lives in a symbiotic relationship with its host, the mother, in which it derives a long-term one-way benefit of nutrition, growth, and protection. I have no idea how any doctor will be able in good faith to say that a fetus is "separate" since it is unlikely to be viable until at least 24 weeks of gestation (at 28 weeks it is considered viable). So what does "separate" supposed to mean? Potentially separate? Separate in terms of DNA? Separate in terms a "soul," that is a central nervous system (I'm partial to a neuroscientific explanation of the soul!)? Perhaps the SD constitution will allow MDs to fill in what this "separate" is supposed to mean - I certainly hope so, otherwise this is a patently false statement.

Calling a fetus a human being doesn't particularly bother me, unless the intention to do so is to persuade a parent-to-be that having an abortion is just like killing a living child (this is different than calling a fetus a person, which has a distinct legal meaning). And that is the whole point of the SD requirement.

Abortion and homicide are as legally and sociologically different as night is to day. Abortion is private and only affects a few individuals. Homicide is deeply disrupting to the community at large. I might not agree with daughter or friend having an abortion, but it doesn't threaten my sense of security or freedom to pursue happiness and prosperity. Having a killer next door does. Hence, the irrefutable and objective need to legislate one type of killing - that of people.

So here' s my pitch to Christians who oppose abortion: indeed, God may not see the difference between killing people and fetuses important - but that is an issue between him and mother (or parents). Frankly, everyone else's views are irrelevant to that very personal relationship a mother has between her fetus and God. Let a woman make her choice and take the issue up with God.

Permitting abortion is a win-win if you think about it. We can protect constitutional rights and preserve freedom without rebuking God's disdain for abortion! If God doesn't like the mother's decision to have an abortion, she will get her punishment, right? And isn't this how free will is supposed to work? Didn't he endowed us with free will so that we could choose between good and bad, and learn from the consequences?

Physician Assists Death of Non-sick Old Lady in Germany

Here's an interesting story from Germany about physician-assisted suicide. Except in this case, unlike those in which Jack Kevorkian was involved, or those cases which are legal in Oregon, the woman who killed herself was not suffering from a terminal illness. Where do we draw the line? Or should we?