I’m afraid this blog post will be a bit of a rant, having just been fired by a patient. This patient was tragic and miserable with the rolling eyes and flaring nostrils of a wild horse confronted with a rattlesnake. And I, dear reader, was the rattlesnake.
And what could have possibly been the crime for which I was so unceremoniously exited from the opportunity of helping one so desperately in need of help? Yes, you may have already guessed. I stopped the IV narcotics.
Those of you engaged, as I often say, in the sacred and unfortunately often profane gumbo that is caring for inpatients must recognize this eternal dance of damnation. You, as a medical provider recognize there is absolutely no identifiable or supportable reason why your professional patient, who has been in and out of various hospitals on a monthly basis for a year or so, should require intravenous narcotics. Logical reasons might include metastatic cancer, recent surgery or vaso-occlusive crisis in a patient unfortunate enough to have Sickle cell disease. Your patient has none of these, but requests, no demands and wheedles for IV narcotics, stating that he/she requires IV narcotics, that the oral medications (be they Tylenol with codeine, Norco, Vicodin, Ultram, Percoset etc ad nauseam) don’t work for him/her, that he/she can’t absorb these medicines; that he/she always gets the IV kind in the hospital, that the emergency room gave it to him/her so why can’t you? And finally you, or rather I, am fired.
And why should this be surprising? Everyone else has given it to him/her.
Mary Shelley wrote a beautiful and compelling book about a scientist who created life out of matter, but who became horrified at what he created. We providers have created these tragic, narcotic-seeking monsters. We as providers have prescribed narcotics for benign musculoskeletal back pain instead of weight loss and physical therapy. We justify it by saying the patient will just get narcotics somewhere else if we don’t give it to them. We prescribe narcotics for tension headaches instead of meditation or massage therapy or active listening. The NIH reported a study recently presented at the American College of Medical Toxicology annual meeting that reveals that there has been a 65% increase in emergency department use of narcotic prescriptions for headache between 2001 and 2010. The largest rise (about 450%) was in the use of hydromorphone. Interestingly, there was no increase in ER prescriptions for Tylenol or NSAIDS during this same time. This trend also occurred at the same time that rates of abuse, overdose and death due to narcotics are on the rise.
But the ER is not the only problem, primary care is not the only problem. WE are also the problem because it is often easier to sit at your computer and order the IV narcotic on cross cover than to go have a difficult, make that nigh impossible, conversation with a monster of our own creation. We create them by giving narcotics senselessly and thoughtlessly without really evaluating the need or efficacy of these medications. And I for one, feel no obligation to continue an intervention or a medicine that I truly feel is injurious to my patient.
So fire me.
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