(3/25/2016) Seeking Painkillers in the Emergency Room, by Helen Ouyang, M.D.
Helen Ouyang is an emergency physician at NewYork-Presbyterian Hospital and an assistant professor of medicine at Columbia University.
Physicians need to know that if they don’t prescribe a narcotic because it’s not clinically indicated, or worse yet, because the patient already has an addiction problem, that they have the backing of administrators at every level, from their own department to the head of the hospital all the way up to state officials. If patients are seeking narcotics and have a documented history of doing so — and become combative or refuse to leave after discharge — they may need to be escorted out of the emergency room by security and their treatment terminated to avoid interrupting the care of other patients…
I’m guessing that every patient who has been diagnosed with — and given the label of –“chronic pain,” has a “documented history” of “seeking narcotics.” When someone is in enough pain to seek medical attention, what do you think they’re looking for? A heating pad?
Will this include any patient who asks for painkillers any time in their lives? If you ask your dentist for some Vicodin after you have a cavity filled, will he write that in your electronic health record? “Patient was seeking narcotics.”
This is what I want pain patients to know: If you go to the emergency room for any reason, keep in mind that you will no longer be able to complain about doctors refusing to treat your pain. No one in the administration of the hospital will help you (unless you have connections).
For those patients who don’t suffer from chronic pain, you will face the same problems. A doctor refuses to treat your pain? Too bad. A doctor refuses to treat your pain for hours and hours, so that she can determine your addiction potential before giving you an opiate? Well, the pain didn’t kill you, did it? Shall we depend on our legal system to put a price on your suffering?
Joe Snyder, Houston
Cartilage in both knees are gone from jogging in early ’70s. Synvisc (hyaluronic acid) injections had limited effectiveness in quelling pain, and less so, as time went by. I have high pain tolerance (I.e., hobbled about with ruptured Achilles’ tendon for several weeks before diagnosis). I was able to tolerate knee pain during the day at work, but at bedtime I became more conscious of the pain and had trouble sleeping. All I required was a small, occasional dose (1-2 times a week….maybe) to allow a semblance of proper sleep time. The two “pain management” docs I saw were glade to take my personal info and charge Medicare (>$600) for a single office visit; and, then deny further “treatment”. Frustrated and sensing few options I had Total Knee Replacement a year ago. Not much improvement. I feel that if I was prescribed a small quantity of (in my case hydrocodone/ acetaminophen) I could have avoided a very risky surgery. I am a 75 years old semi-retired pharmacist.
Mary DeForest, New Mexico
I guess this is a Prebyterian problem. I can’t get anything for pain for obvious trauma, like being attacked by dogs. I had part of my nose-including bone-removed, a section of my lip, and tissue between those 2 places removed. I was in agony, and I had nothing for the pain. Presbyterian is cruel. I’m told that it is because I’m a senior citizen and they don’t want me addicted at this age. I don’t even take NSAIDs because of stomach problems and gastroentology keeps telling other doctors to tell 60+ patients to take NSAIDs, because of internal bleeding.
Sometimes those of us in chronic pain end up in the ER because our pain spikes and the meds we *have* are no longer sufficient to keep it under control. Chronic pain isn’t a steady state, it has peaks and valleys. Sometimes my migraines are worse than others. Sometimes I can get rid of them with the meds I have, sometimes it gets bad enough that I need stronger medication, and the only place for that is the ER. I do get meds from my pain specialist, but he tells me to go to the ER when those stop working, so what should I do?
Your doctor tells you to go to the ER because he doesn’t want you calling him when you’re in a flare. Because he won’t help you, just like the ER will no longer help you. You asked what you should do, when the answer is obvious to me: All these “experts” are telling you to suffer. And to stop asking for help, because they refuse to give it.
Government agencies played a huge role in creating the problem during my medical school years and residency “pain is the fifth vital” was pounded in…
Many doctors blame the fifth-vital-sign procedure for drug abuse and addiction, as if that makes any sense at all. And, pray tell, what’s the alternative? Doctors should stop asking patients to rate their pain? Just like Medicare should stop asking patients to rate their doctors, right?
Health Nut, Minnesota
Working in the medical field, I disagree that the fault of opioid abuse falls into the hands of physicians. I remember our hospital being “written up” by the insurance companies for not providing total pain care of our patients as our ER physicians said this was going to happen if we complied with federal government in management of pain. We offered non narcotic pain relief and counseling instead. But the government forced our hand on this issue. We are, once again, acknowledged for our low patient satisfaction scores for our decreased opioid use in our ER. Its been a lose-lose situation for us, and I can imagine, most hospitals!
An insurance company writing up a hospital for not following federal guidelines for the management of pain? Huh? I’m too tired to look up the specifics of these guidelines, but as far as I know, it’s mostly about doctors rating patients’ pain as the fifth vital sign. But that’s not only a requirement of the federal government, it’s also followed by international organizations, too.
I’m sure there are a small percentage of ER patients who are just looking for drugs to treat an addiction, but the majority of people who are forced to go to the ER are not drug addicts. People use everything they can to manage pain, including over-the-counter drugs, ice, heat, etc., before they even get to the ER. So, an ER offering only “non-narcotic pain relief and counseling” is the stupidest thing I’ve ever heard.
And then, when you place blame on low patient satisfaction scores, you’re basically just blaming the patients for not agreeing with your anti-drug ideology. You mean patients in pain are not satisfied with anti-inflammatories and counseling? Gee, who would have thunk it?
The heroin dealer around the corner won’t say no
Then let them go to the heroin dealer.
But remember that 9 out of 10 won’t to a heroin dealer.
Instead, they will go through withdrawal and get their lives back.
Yes, it’s probably true that 9 out of 10 patients denied treatment for pain won’t go to a heroin dealer — it’s not like they’re easy to find. But suggesting that most patients who go through withdrawal will then get their lives back is utter nonsense. In fact, when it comes to the treatment of addiction, the opposite is usually true — those who experience the torture of withdrawal are usually even more motivated to relapse.
Let’s see what else Honeybee has to say, shall we?
To be fair, it doesn’t sound like any legitimate user is going to be denied any drug.
I don’t see the problem. Yes, there will be a few more hoops, but nothing ridiculously unreasonable. Huge mistakes were made with alcohol and tobacco; I’m glad the govt and the doctors are trying to prevent a similar disaster with opioids/opiates.
I suppose there will be a lot of people who refuse to see the problem — that is, until they experience the problem for themselves. And it’s unreasonable to compare alcohol and tobacco to opioids, just like it’s unreasonable to compare opioids to cannabis, especially when we’re specifically talking about the potential for addiction. This is a person who obviously believes the drug war has been a success.
Note how many of the chronic-pain claimants have a host of other health issues and constant problems abiding by the simple 30-day refill policies (“I got sick” or “I went out of town” or “The pharmacy charged too much”). This is textbook addict behavior and addicts want their drugs on demand with no questions asked, no hoops presented.
So should the doctors enable the addict or cause them to suffer withdrawal? Objective observers will say to step the addicts down gently but firmly. Yes, they will suffer. Yes, their pain will feel worse. But they will survive. Cutting them off is necessary, but we also need to help them withdraw.
Hillary Clinton, is that you?
familydoc, brooklyn, NY
I reach for narcotics rarely now and haven’t found my patients to be in more pain. It may sound lame to hear doctors recommend therapy, heat and a variety of complementary approaches to pain but I’ve found it returns patients to functionality faster than masking the pain with narcotics…
Perhaps your patients stopped complaining to you about their pain, or maybe they see a different doctor when they’re in pain. Perhaps your patients have learned to find their pain relief elsewhere, instead of from their doctor.
What sounds lame is to pay a doctor to tell you to plug in your heating pad. Too bad you can’t take a heating pad wherever you go, right? You went to medical school for that? I’m paying you to refer me to a heating pad and a therapist?
(It’s like these doctors have never heard of the internet, where advice is plentiful and free.)
I think it’s hilarious that doctors have created their own downfall, making themselves obsolete. Just freaking hilarious. 🙂