By Kristen Sandel, MD, Brahma Sharma, MD, and Giffin Daughtridge
Note: Three PAMED members share their experiences with addressing suspected prescription drug abuse with patients. Pennsylvania’s opioid abuse crisis was the focus of the fall issue of Pennsylvania Physician magazine. These perspectives are reposted in this blog with permission from Pennsylvania Physician.
Kristen Sandel, MD, is an emergency medicine physician at Reading Hospital, and is the Young Physicians Section Trustee on the PAMED Board.
As an emergency medicine physician, I have been in numerous situations in which patients were pill shopping or requesting controlled substances. While each circumstance is unique, they all have a commonality to them. There have been many instances in which I have been conflicted when presented with this issue, as I want to believe that every patient who presents to the Emergency Department has good intentions to improve his health and well-being. However, I do not want to perpetuate a substance abuse problem.
Emergency physicians, due to the nature of their specialty, do not develop the same patient-doctor relationships that many primary care physicians are able to foster. We see patients for episodes of care, but are not able to follow them throughout of the course of their illness. There may be a lack of knowledge of a patient’s prior medical or substance abuse history and physicians can often be persuaded by their patient to prescribe these requested medications, especially in the attempt to ease pain.
Physicians must have a keen insight into the treatment of chronic pain and their patients’ other medical conditions. We need to have realistic and honest conversations with patients concerning their symptoms, as well as their expectations of treatment and follow-up care.
Unfortunately, this conversation often takes additional time and is more difficult than just giving in to requests. It is important that patients and their loved ones understand that there are many alternative treatments and other options for patients who have chronic pain. These options often do not include opiates, or even daily medications. Taking the time to have this frank conversation may be the best treatment that the patient has ever received.
Brahma Sharma, MD, is a Cardiovascular Disease specialist from Allegheny County.
I think our role is paramount in the dealing with the problem of "pill popping." We need to act at multiple levels not only in identifying the problem but in managing it, and reporting it in appropriate situations.
Start with the adage "Physician heal thyself." I would educate and keep myself up to date about the enormity of this problem and raise my awareness. Our encounters with patients should be meaningful, and prescribing a pill should not be a substitute for a thorough evaluation. Many of these medications are prescribed for symptoms whose root cause is psychosocial or in life style choices which require more time and attention than we often have available at that given moment. But I would try to spend more time in discussion with the patient rather than writing a quick prescription.
When I do need to prescribe, I make sure it is appropriate and it is short term. I will educate the patient about potential side effects and the risk of long-term dependency and abuse. I advise my staff to monitor requests for refills and we look for subtle signs of overuse or overdose in our clinical encounters. I tell patients not to share and keep these drugs in a safe environment.
If I do run in to the problem where a patient started out sincerely but got off track, maintaining an honest relationship with a patient goes a long way. This keeps the door open for the patient to admit and rectify the course of action. There are certain situations where the larger public interest or legal ramifications have to be kept in mind so we have to maintain our professional standards and responsibilities.
There is some role for alternative and complimentary medicine and we should explore other avenues like mindful meditation or acupuncture. There is scientific evidence to support these treatments in reducing the need for pain medications, as well managing depression, anxiety, ADHD, PTSD, and insomnia and related disorders. I always mention these alternatives in an appropriate cultural context, and if that is a direction they choose, guide patients to well-known and respected therapists.
Giffin Daughtridge has finished his third year of medical school at the University of Pennsylvania's Perelman School of Medicine, and he is now completing a Masters of Public Policy as a Zuckerman Fellow at the Harvard Kennedy School.
During a recent shift in the emergency department, a patient came in with neck pain following a low-speed automobile accident days before. During his evaluation, he requested Motrin, and without second thought, I included it in my plan.
When I presented to the attending, he told me not to give the medication and rather recommend non-medical therapies with the patient like massage, heating pads, and stretching as they were more effective for that type of pain and had none of the side effects of an NSAID [nonsteroidal anti-inflammatory drugs].
Unless that patient got a high from Cox-2 inhibition, he was not a drug-abusing patient, but this example highlights the physician’s role in dealing with anyone who comes to the doctor claiming to be in pain and expecting a pill.
Whether that person actually has a source of bodily pain, or is looking to placate an addiction, both patients need treatment. Rather than classify as drug-abusing or not, we must make our treatment plans independent of the patient’s desire.
Because it is often easier said than done to deny a patient a medication they are convinced they need, I came up with a simple two-step process that I intend to walk through every time I consider prescribing a pain medication to a patient:
- Decide if the patient needs treatment or not. This step should recognize that organic pain is not the only indication for treatment.
- If they need treatment, be it pain or addiction, prescribe the most sensible treatment considering the full arsenal of medical and non-medical therapies.
Rather than classify as drug-abuser or not, we should classify as needing treatment or not. Once that decision is made, the patient will expect us to choose which medication to use, but we must also consider whether a medication is the best therapy.