As a resident, I still remember the day I was so excited that I could prescribe narcotics on my own. I had taken my USMLE part 3 and paid for my DEA number so that I could moonlight at a local community hospital. As an added bonus, I was no longer reliant on an attending to write narcotics scripts. While this may sound trivial, word spread through our residency like wildfire. That week, I got paged daily by an intern whose attending physician had left for the day, and they had patients to discharge on narcotics. After all, it was not uncommon to send patients home with narcotics because they were “having pain” and they needed pain medications to give them the edge they needed to stay out of the hospital.
I did not think much of this until 5 years ago, I saw a patient “RC” acutely suffering from urinary retention and priapism. We continued his narcotics started in the ED due to his excruciating pain. His exam was not revealing, but his pain was so horrible that I truly felt awful. The urology consult note mentioned something about consider a pain consult for alternative pain strategies. Imagine my surprise when the pain service confirmed we were observing textbook drug seeking behavior and requested we stop his narcotics since all his symptoms stemmed from opioid abuse. It sounded so cruel at the time, but deep down, I knew the moment of truth had come. I mustered the energy to tell RC we would be stopping his narcotics. To say it did not go well would be a gross injustice. After he threatened physical abuse, pulled out his IV and screamed as he ran down the hall, security restrained him. Psychiatry helped me that day at my urgent request- it turned out that he was getting the pills from his mom, who sadly was likely addicted too. He was ultimately transferred to inpatient psychiatry to seek help for his addiction.
It was that moment that I knew we had a problem. I did not know what to do about it, but I knew the pendulum had swung too far, and it was too easy to get opiates. Even if we did not give it to him at our hospital, RC told me flat out that he would go to another hospital to get them. Two weeks later, I got a call from a community hospital ER saying that RC, “my patient,” was there requesting narcotics for his pain. I asked them to repeat that part—apparently, he gave them my name as his primary doctor. I was dumbfounded…and then they said he insisted I would explain everything to them…and of course, I did…in painful detail including that he should not get opiates. After all, he knew what I was going to say and this was his way of asking for help.
This was the story that was going through my mind when the US Surgeon General, Dr. Vivek Murthy, the nation’s top doctor and a hospitalist, visited the University of Chicago this past week, hosted by our Senator Dick Durbin to shed light on the opioid epidemic. He unveiled his new #TurnTheTide strategy. The panel also included voices from on the ground clinicians and educators working to contain the epidemic. Dr. David Dickerson, an anesthesiologist who directs the acute pain service at the University of Chicago highlighted the concept of stewardship for pain medications and Dr. Audrey Tanskley, a primary care physician and clinician-educator, outlined the need for better training that catalyzes the changes we need.
As hospitalists, you may wonder what this means for us…. well, a new Journal of Hospital Medicine study sheds light on the specific issues we face. Not surprisingly, hospitalists are influenced by negative experiences and also admit turning to opioids to ensure timely discharges and reduce readmissions despite this practice feeling “cheap and dirty.” In response to concerns of hospitalists and others about publicly-reported patient satisfaction with pain control, CMS has responded by retooling their measure to focus on screening for pain, as opposed to treating pain which incentivizes opiate use. As editorialist Shoshana Herzig brilliantly lays out, we don’t know how to have difficult conversations about pain. We instead rely on prior negative experiences as opposed to safe systems, like state prescription drug monitoring programs and guidelines, like those from the CDC, to promote better decisions.
Our goal should be to ensure that patients like RC are not bouncing around in a system where getting opiates is too easy. This will require all clinicians to step up to #turnthetide on the opioid epidemic – it’s an all or nothing for the win. After all, excitement is the last thing anyone should feel when prescribing narcotics. Ever.
Join the Journal of Hospital Medicine for #JHMChat on Monday, September 12 at 9 p.m. EDT when we discuss the opioid epidemic and recent research with editorial author Shoshana Herzig (@ShaniHerzig on Twitter). Learn more and register here for CME for your tweets!
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