July 2009

I was recently asked by a police officer why doctors prescribe so much opiate medication knowing full well that we are in the midst of an addiction crisis.  Many people are hooked on opiates; pills, patches and injections, and the problem is getting worse.  Anyone who works in the ER is aware of “drug seeking” patients who may not have a real medical problem, but repeatedly come into the ER seeking narcotics for various types of pain.  The police officer sincerely wanted to know why doctors are so willing to prescribe high doses of opiates when the costs of addiction are so high, and this question has recently been brought into the spotlight with the death of Michael Jackson.

It’s a difficult question to answer, but I feel there are several sources of pressure put upon physicians to provide these medications.  First, when dealing with a patient who is in pain, or appears to be, it can be impossible to sort out when a patient needs opiates for legitimate reasons, and when it is merely feeding a long term addiction.  We are trained to provide comfort and relief from suffering to our patients, and we generally will err on the side of treating pain, rather than withholding addictive medications.

Additionally, physicians and hospitals are now obsessed with patient satisfaction.  We are monitored constantly, at the level of the hospital, the ER and individual physician.  When satisfaction goes up, physicians are rewarded, and when it goes down their very jobs may be at stake.  If a doctor takes a “hard line” with opiate seeking patients, satisfaction numbers will predictably plummet.  Not giving some patients the opiates that they want and expect will often times result in arguments, profanity, and calls and letters to administration.

Finally, pain is now considered by the medical establishment as the “new vital sign.”  When patients present to the ER, they are asked to rate their pain 1 through 10, and then this number is followed all the way through discharge or admission.  The implications with regard to opiate addicted patients can be profound.  If a person states they have a 10/10 pain on arrival and it has not decreased whatsoever at discharge, the physician appears to be at best complacent, at worst sadistic.

For the above reasons, I believe the medical establishment is helping to fuel the opiate crisis in the US, and it is time to re-evaluate our expectations and our processes.

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