Posts Tagged ‘hydrocodone’

Vicodin found on a plane

December 18, 2016

You wouldn’t believe the stuff that I’ve found

On the road, the sidewalk, or ground

But it gave me a chill

When I picked up a pill

That was tan, not square, and not round

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, traveled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. Assignments in Nome, Alaska, rural Iowa, and suburban Pennsylvania stretched into fall 2015. Since last winter I’ve worked in Alaska and western Nebraska, and taken time to deal with my wife’s (benign) brain tumor. After a moose hunt in Canada, and a couple of gigs in western Iowa, I’m back in Alaska. Any identifiable patient information has been included with permission.

During my med school years at Michigan State, the student paper carried a piece written by a runner. He kept a journal not only of his mileage, but of the money he found.  The piece pointed out that as time progressed and the value of the dollar decreased, he found more and more change.

I read that before I knew about complex systems, and while I took his point, now I realize that as time went on, he probably improved his money finding skills.

I find money, too, but I don’t run any more. And the amounts that I find progress with the years, so that what I found this summer, in the triple digits, stands as my all-time record.

I’ve also found gold and diamonds, but so rarely I can tell you the weather on those days.

Cycling or strolling, I find tools, as well. I pick them up because I usually end up needing them.  An acquaintance says I find things because I’m a hunter.

Getting onto the plane in Omaha, I found a pill on the floor. It didn’t require a lot of skill; the tan color didn’t match the blue carpet.  After we settled into our seats, I pulled out my smart phone and used the Epocrates pill ID app.  I entered the imprint and the shape and discovered I’d picked up a Vicodin HP, containing 300 mg of acetaminophen (also called Tylenol) and 10 mg of hydrocodone.

We have a nationwide epidemic of opioid addiction; the government has acknowledged that fact to the tune of billions of dollars of funding. Hydrocodone is one of the most popularly abused drugs.  Physicians, pushed by the Pain, the 5th vital sign initiative, and driven by patient-satisfaction survey-driven reimbursement, bear most of the responsibility for this epidemic.

I had to wonder about the person who lost the Vicodin. Was it the one it was prescribed for?  Did they want it medically or recreationally?  What did the patient say to the doctor to get the original prescription, and how many times did that particular pill get remarketed? What drama and irony went into the backstory?

I hope that the fact of finding that pill doesn’t signal the ease with which doctors prescribe such meds, but I suspect it represents the inflation of the supply side of the abusable drug market in this country.

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Two cups of coffee after a bird strike.

September 2, 2015

A bird sure made our plane late

We missed by a hair at the gate

So a bit of caffeine

Kept my wit keen

With a steady patient flow rate.

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record System (EMR) I can get along with. I spent the winter in Nome, Alaska, followed by assignments in rural Iowa and suburban Pennsylvania. After my brother-in-law’s funeral, a bicycle tour of northern Michigan, and cherry picking in Sioux City, I’m travelling back and forth between home and Pennsylvania. Any patient information has been included with permission.

The smallest bird striking the largest commercial aircraft in the US in the 21st century demands an airframe inspection.  The regional jet coming into Sioux City ruined the day of a dove.  And so we sat in the departure lounge for a couple of hours till the inspection and the inevitable paperwork.

In medicine, the documentation takes as long as the visit, and I would imagine in aviation it takes longer.  I napped and I read.

Late to leave, late to arrive, we got to Gate H1 in Chicago O’Hare just after the flight closed.  The gate agent took care of the rebooking cheerfully and professionally.  He gave us meal vouchers and better seats.  We strolled the airport for a while, I got a torta and guacamole.  We settled down in the seats designed for discomfort.  I napped and I read some more.  We took off on time and got into Pittsburgh just past midnight.

I had slept much of the day at that point.  Connie, the GPS, took us on slow back roads that would enhance a leisurely Sunday afternoon, but doubled the drive time.  We wasted no time at check in but didn’t roll into bed till 2:00AM.

I had not one but two cups of coffee with breakfast.

It doesn’t sound like much but, outside of chocolate, my body doesn’t see much caffeine.  Thus a little goes a long ways.

I nearly fell asleep before the first patient arrived at 9:30.  After that a steady, reasonable pace kept me awake and engaged and despite my initial dread I found myself grinning in the afternoon.  The PA arrived at 2:00, and the reasonable pace continued.  We took care of 48 patients in the 12 hours.  I got to speak Spanish with 2 (though both spoke English well).

This late in the summer, poison ivy continues to bring misery to multiple patients per day.

Sometimes patients with chronic pain ask for opiates, drugs in the same class as morphine.  But as time has gone on we’ve found that while such medications can ease pain in the short-term, in the long run they fail to relieve pain and they ruin functionality.  Frequently the patient will say in one breath that they need more of a drug that doesn’t work.

I wrote a prescription for a 5 day supply of hydrocodone for a person with a broken bone.  I hadn’t needed my DEA number for more than six weeks.

I give a lot of warmth and understanding to the people who have chronic pain at the same time I explain why opiates are a bad idea.  I print off a copy of my post, https://walkaboutdoc.wordpress.com/2012/12/09/pills-and-skills-you-need-a-tool-set-to-deal-with-chronic-pain-caution-longer-than-average/.  I get mixed reactions.  Those serious about pain management read it carefully, those serious about just getting the drugs pitch a fit and stomp out.  And I can’t predict who will do what before hand.

I left the clinic at 8:37, ready for bed.

If you use caffeine rarely, it will serve you as an ally.  If you use it habitually you will be its slave.

The root that Mayo missed: whittling down the med list

May 18, 2015

Some of the things I told my patients

May 13, 2015

Foxes, itches, triumph, and hunter: on the cusp of leaving Nome

April 1, 2015

On the med list I’m pulling a switch
‘Cause my patient came down with an itch
Now they’re getting the sleep
That’s restful and deep
And for trazodone I found the right niche

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I am back having adventures in temporary positions until they have an Electronic Medical Record (EMR) I can get along with. Right now I’m back to Nome from temporary detail to Brevig Mission.

I took care of a patient with a very bad diagnosis and a very bad itch. I will leave it up to the specialists to try to change the course of the disease, here in Nome I will try to relieve suffering. Because itch in the context of unrelenting pain constitutes torture. We looked over the med list.

Me: Aren’t you allergic to codeine?

Patient: Yes, it makes me itch, real bad. Same with the hydrocodone.

Me: Stop picking at yourself. Why do you take the oxycodone?

Patient: Beats me. Doesn’t work. That’s why I finished ’em early.

Me: If they don’t work, why do you take it?

Patient:

Me: Maybe oxycodone is making you itch. Let’s try stopping it.

Patient: But how am I going to sleep?

Me: How are you sleeping now?

Patient: I’m not. Those pills don’t work.

Me: Maybe we should stop them.

Patient:

Me: How about if I give you a sleeping pill to help you sleep and you come back next week. How about trazodone?

It took some explaining, but the patient came in, looking fresh and happy and focusing a lot better, having slept well 4 nights in a row, and now having much less pain. Because (everyone knows) that good sleep helps a person deal with pain.

And another demonstration of the principle of ABCD (Always Blame the Cottonpickin’ Drug).

***

I can post this about the young man because I got permission from him and his mother and because everything is on Facebook. Well on the way to being a hunting legend at age 14, he got his first polar bear at age 11, same year he got his first bowhead whale. He has lost track of the number of walruses he’s gotten so far this year. I still won’t publish his name or what he came in for.

***

I stepped into my cubicle about 10 in the morning and saw a red fox run past.

Foxes hunt at night, any abroad by day raises suspicions of rabies. At home, if I see raccoon, skunk, or fox outside of dusk, dawn, and night, I will seek a weapon to dispatch the animal. In Barrow, we assumed rabies in all arctic foxes.

The furry red animal ran along the north side of the building, around to the west. I said, loudly, “There goes the fox!” and strode briskly to the other end of the clinic to try to get another look; I worried it might head to town. I didn’t see it again, and decided it dens either under the hospital or in the maze of construction dross nearby.

****

The first patient of the day felt really, really good after the vitamin B12 shot yesterday. Best in years; better sober after that shot than drunk.

Which made my day.

***

I leave tomorrow after an abbreviated afternoon clinic. Staffers have come in to wish me well. I got a great going-away card, a very trendy tote bag, and a pair of hand knit socks. Along with the story of the wool (starting with the sheep) and the WWI-era sock knitting machine.

Exercising my buprenorphine waiver but going back to Alaska

February 26, 2014

I wonder if this is the way

With all the things I could say

I’m away and I’m off, To the Island Metkoff.  

I’m taking vacation today

SYNOPSIS:  I’m a family doctor from Sioux City, Iowa who danced back from the brink of burnout in 2010.   Honoring a 1-year noncompete clause, I did short term medical work in Keosauqua, Iowa, Grand Island, Nebraska, Barrow, Alaska and New Zealand.  I came back to work in a part-time position with a Community Health Center, and I’m now down to 40 hours a week.  I’m taking a month to work in Petersburg, Alaska, 

For the last week I’ve warned my patients  that I’ll take a month of vacation for March.  I’ll work in the same clinic in Southeast Alaska where I worked for 2 weeks in August.

My addictionology practice has grown by leaps and bounds in the last month, and the news of my upcoming time off has been particularly hard on my opiate addicted patients.

The narcotic or opiate group of drugs includes morphine, opium, heroin, hydrocodone, hydromorphone, meperidine, fentanyl, codeine, and others.   The epidemic of addiction to these drugs has started to strangle the country, until deaths from overdoses of legal narcotics surpassed deaths from motor vehicles in 2012.  Already, the US uses more narcotic pain killers than the rest of the world put together.

Some attribute this surge in dependency to a government agency’s decision to make pain the 5th vital sign, and to sanction doctors who failed to address a patient’s pain level that exceeded 5 on a 10 point scale.  In fact the opiate use started to grow logarithmically that year.

The problem usually starts when a person has a legitimate injury, such as a broken leg, and gets a prescription for a pain reliever, then gets hooked by taking a friend’s leftover pills.  Abuse escalates in short order, many start onto heroin because it’s cheaper than the prescription stuff, they lose their job/house/spouse/car/assets/family and when they find themselves with absolutely nothing they realize they have a problem.  Then they come to see me.

If I wait till they’re in full-blown withdrawal (yawning, tearing,  diarrhea, insomnia, aching) I can prescribe buprenorphine, but only because I have a special license to do so.

The requisite education, done online, only cost me 9 hours; I got the waiver last summer  to back up one of my partners while he had medical problems.  I didn’t write my first prescription for it for 6 months.

The medication blocks them from getting high, and can stop a lot of pain.  Success demands close monitoring and frequent blood tests.

Patients don’t seek help until chaos dominates their lives.  I don’t get to retell the dramatic , ironic stories because of confidentiality.  The temptation to judgementalism runs strong in my business, but especially in addictionology, yet I know I will finish my day with more energy if I approach each patient with an attitude that acknowledges the mistakes of the past and emphasizes the need to move on.  And really, the patients do the best when they take control of their lives.

But they have a lot of emotional needs and tend to bond tightly to people who listen without judging.

Fortunately I have a partner with more experience with that drug than I have.