Posts Tagged ‘narcotics’

The scientific method applied to a long, failing med list

May 14, 2015


No illusions: lies and drugs.

December 15, 2012

This rule I won’t even bend,

I no longer even pretend

I see no excuse

For those drugs of abuse

That make up a frightening trend.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

Last year legally prescribed narcotics killed more Americans than the bullets or the cars.  This frightening statistic comes after a four-year near-logarithmic increase and matches the same trend in the number of narcotic pills prescribed.

Several layers of government keep track of the use of certain medications, the ones most susceptible to abuse, now referred to as controlled or scheduled drugs.  I have to have a slip of paper from any state government where I practice and the federal government to prescribe any narcotic, also addictive tranquilizers, most sleeping pills, and testosterone.

I tend to reach for those drugs as a last resort.  We have a lot of other things to treat pain and anxiety and sleeplessness; nonetheless controlled medications have their place in the work I do.

Of course a lot of patients disagree with me as to how big that place needs to be.

As required by my state licensing board, I took a two hour video course in the proper prescribing of pain medications, exhorting me to watch out for personal and family history of crime or substance abuse, past incarcerations, or frequent missed appointments.

More than half of my new patients don’t show for their first appointment, which leads me to wonder about substance abuse even before I see them.

Our practice includes a large number of people who have done significant time behind bars; I don’t want to know their crimes.  Everywhere I’ve practiced, abuse of alcohol and other substances runs rampant.

So, all in all, I keep my suspicions high, particularly when a new patient comes in with a long med list including tranquilizers and narcotics.

The number of good reasons to prescribe long-term narcotics continues to dwindle; for example, evidence-based medicine shows the opiates lose their effectiveness for back pain after 8 weeks.  I never prescribe large numbers of the two most popular short acting tranquilizers, alprazolam and lorazepam; if the person really has that much anxiety I recommend the long-acting but less marketable cousin, clonazepam.

Really, the problem comes down to diversion: someone other than the patient taking the prescribed drug.   

Thus, for those patients on long term controlled medications, we make sure they sign an agreement that says they won’t share those drugs, and that they’ll come in, when asked, for a urine drug screen and pill count.  And that they won’t seek controlled substances from more than one provider. 

I used to believe people who would tell me they used to abuse drugs but named a date when they quit.  Most can tell twelve-step stories. 

Two of my patients flunked the urine test this last week. 

I’ve asked our case manager to contact them, to see if they’ll come in to get counseling.

I don’t hold high hopes.

Morning rounds before Thanksgiving.

November 22, 2012

I started my work in the dark,

At the hospital next to the park.

Up and down floors

And in and out doors

The contrast and irony stark.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  In May 2010, I left my position of 23 years, and honoring my non-compete clause, traveled for a year doing locum tenens work.  In June of 2011 I joined up with the Community Health Center, which provides care for the underserved.  I’m now working part-time, which, for a doctor, means 54 hours a week.

I enjoy starting early.  On Mondays and Wednesdays I do my group’s hospital rounds, and I like being in that first wave of doctors that hits the nursing floor before the chaos of shift change.

The more efficient I get, the more I enjoy inpatient work.  A doc can save a lot of time if he or she starts at the top and works down but today I started with the sickest patient admitted overnight, on the fourth floor, not the sixth.

I gained time because comatose patients don’t talk, and lost every minute trying unsuccessfully to access the outpatient record electronically.   Faced with an unconscious, non-English speaking patient, no available family members or other source of data, I did the best I could.  I left orders for social workers with interpreters to locate family and clarify the Do Not Resuscitate status.

Down the hall, the next patient, also requiring a history and physical, presented a dilemma: a narcotics addict with a legitimate, acutely painful physical problem.  I wrote orders for generous doses of narcotics in a patient-controlled anesthesia (PCA) pump.

I dealt with nurses panicking about a rumored bedbug found in the ER, pointing out that wearing infection control gowns , gloves, and caps wouldn’t do anything to prevent the spread of real bedbugs.

On the other side of the nurses’ station, I discharged a large patient with a 14 item problem list, who will need outpatient IVs for weeks.

I didn’t see the last patient on that floor, absent for treatments across town, but the ward clerk told me when to return.

Five minutes here and there add up, chasing patients wastes time, and I could feel efficiency fleeing in front of me.

I set off upstairs.

Some people don’t stop unhealthy behaviors soon enough, and physicians like me sometimes have to sit down with families and talk about time expectations measured in a week or two.  We discuss ventilators, resuscitation, and the vital business of saying what you have to say to the people in your life NOW because you might not be around to say it on Monday.  The patient said, “I’ve had a good life.  I’m not afraid to die.”  I talked with the consulting subspecialist who confirmed a very poor life expectancy, and gave me a decades-old formula . My calculator came to 63 when anything over 32 means less than a dozen days.

Three doors down I discharged another patient, mixing Spanish and English, and getting pieces of a fascinating life story, an odyssey crossing and re-crossing international boundaries.

On the other side of the building, inside the locked doors of the psychiatric unit, I discharged a person showing remarkable insight and taking complete personal responsibility, after a discussion of the fine points of a borderline vitamin B12 levels.

Two stories down, I discharged another from the orthopedic floor, who also had vitamin B12 problems and severe vitamin D deficiency.  Two doors up the hallway, the patient showed progress but not enough to leave.

Up the stairs again on the fourth floor, five minutes fled while the patient arrived from across town.  Optimism suffused the visit with four family members and a patient with a grim diagnosis and a good attitude.

Two floors down another admission involved a newborn, with the shortest of histories and the most efficient of complete physicals.  I spent more time talking with the parents than actually examining the patient.

Thus in the course of my hospital morning, I took care of 8 patients including 3 admissions and 3 discharges (with discharge summaries).  Diagnoses included metastatic cancer, end-stage liver disease, hip fracture, kidney failure, dementia, end-stage pulmonary disease, bipolar, alcoholism, depression, diastolic heart failure, sepsis, epididymitis, diabetes, hypertension, coronary artery disease, stroke, narcotics addiction, sepsis, urinary tract infection, and completely normal.  Life expectancy ranged from less than a week to 86 years.  Family involvement went from none to surrounded by warmth, and emotional impact of disease ran the spectrum from despairing acceptance to outright joy.

Contrast is the essence of meaning.  I finished before noon.  I lunched with my colleagues in the doctors’ lounge, discussing hospitalized patients with consultants. The erudition beat the chili.

Fourteen hours of a zoo of a day.

February 17, 2011

I don’t do this because of the pay,

Going straight into the fray

     From eight until ten

     Like the old headless hen,

It’s been a zoo of a day.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  Avoiding burnout, I’m taking a sabbatical while my one-year non-compete clause winds down, having adventures, visiting family and friends, and working in out-of-the-way places.  Currently I’m on assignment at the hospital in Barrow, Alaska, the northernmost point in the United States.

I’m writing this after fourteen continuous hours of caring for sick people trying to get better, sick people trying to stay sick, well people pretending to be sick, and a few well people just wanting to go back to work.

I tried to take care of five people who came out and said they didn’t trust me, then tried to bully me into narcotics prescriptions.  I pointed out to them that if they really didn’t have confidence in my judgment they wouldn’t accept anything I would prescribe, and the only thing they should take from me is an arrangement to see another doctor.

A recurring theme today, just like an episode of a TV doctor show, involved a schizophrenic with a horrendous medical problem that cannot be dealt with on the North Slope.  We discussed the patient at morning rounds, I made several calls to Anchorage and received varying combinations of arrogance and sympathy from the Big City.

I placed a cast with the advice to the patient for prompt follow-up if the cast got too tight.  Which it did.

Influenza and post influenza problems saturated the walk-in clinics.  People slip on the ice and sometimes break things, but mostly just hurt for a couple of weeks.  I explained to a lot of people that if it didn’t hurt bad enough to come in for the first five, six, or eight days that they didn’t narcotics today, and they should expect to be sore for several days.

The Inuit smoke a lot of marijuana, which has marginal legality here.  But they smoke it now like hippies smoked it in the sixties and a lot of folks haven’t been unstoned for decades.  Some of them hunt stoned.  I see health problems related to cannabis abuse.

Instead of eating dinner, I waited twenty minutes to talk to a pediatrician at ANMC (Alaska Native Medical Center) because the phone operator didn’t read the call schedule correctly.

When I finally connected to the surgeon/gynecologist/pediatrician, I received cogent, useful advice in a time efficient fashion.

Seventy percent of my business came from tobacco, alcohol, or marijuana. Twenty percent came from influenza.  Ten percent came from bad luck or overeating or both.

And I saw something I’d never, ever seen before.  I didn’t even ask for permission to write about it, even if the answer had been yes, I wouldn’t have written the details.