When I was in my family medicine rotation, it seemed like every other patient we saw was there for pain medications.  I don’t think that is much of an exaggeration either.  The first thing I learned to do on that rotation, which makes it the first thing I learned to do in clinical rotations, was write a prescription for narcotics.  After only a few days I decided I didn’t want to do family medicine because I didn’t just want to be a drug dealer.

But the truth is, today all doctors are drug dealers.  So many of our patients in the hospital are on opioids for pain relief.  Not all of them are drug addicts, but many of them are, and the sad truth is you often can’t tell which is which.

I recently had a patient admitted to the hospital who was assigned to me.  The second day I came to see her she rated her pain as getting worse, 7/10.  She asked to be switched from oral Dilaudid (hydromorphone) to IV.  She also requested a PICC line (peripherally inserted central catheter).  To be completely honest with you, I had to Google both of those things (give me a few weeks people, I am still new to all this).  What kind of patient knows so much about pain medications and deliveries?  A drug addict, that’s who.

I love my patient.  She is a nice Turkish lady who is legitimately sick.  She also has a history of narcotic drug abuse.  As do many of my patients.  And in only a few weeks of rotations, I have learned more about opioids than anything else.  I have learned to be suspicious of anyone asking for them.  I don’t want this to be the case, but it is.  I hate it.

My preceptor has talked about this topic with me multiple times.  “It makes me sick,” he says.  No doctor likes it, but this is the world of medicine right now.  I read an article today about patients rating their physician.  It states that patient satisfaction is given too high a priority.  The most satisfied patients tend to be drug addicts whose physician gives them what they want.  Of course they will give them a high rating.  But is this a good thing?  Obviously not.

How did things get this way?  Other countries don’t have nearly the high rates of narcotic pain use as we do in the U.S.  According to my preceptor, the fault lies with doctors.  “We did this,” he says.  I think he is right.  But there is also little doctors can do.  If my preceptor refuses someone their drugs, they call the hospital and complain, and pretty soon he gets a call asking him what is going on, and why aren’t his patients happy?

It just makes me really sad.  My patient is a nice lady.  I have spent a lot of time just talking to her, and I feel bad that she is in such a dark place in life that she needs drugs.  Drug addiction happens to good people, too.  So many people start out with a serious illness or recurrent surgeries that they need pain control, but eventually they can’t live without it.  My doctor said he sees a ton of drug dependence in people with Crohn’s Disease.  It makes sense.  There is no cure, and these people are in pain.  Eventually they just become dependent.

It’s time for things to change, and I think a lot of doctors are realizing that.  I have been lucky to have some really great preceptors already who really are trying to help solve the problem.  In the family medicine clinic, patients receiving regular opioids have to sign a pain contract.  They get random urine drug screening.  They have to comply with what the physician recommends in terms of referrals to pain clinics and physical therapy, etc.  He also makes a genuine attempt to wean them off drugs.  In the hospital, my preceptor regularly refuses to give patients opioids.  He doesn’t leave them hanging, but he also doesn’t just submit.  He doesn’t care if they call and complain; he really wants what is best for them, and oftentimes, that isn’t opioids.

Even though many patients are drug seekers, my preceptor reminds me to never assume that.  Always assume the patient is telling the truth.  If you assume people are lying and don’t do a thorough history, physical exam, and work-up, something could get missed, and that would really be bad.  I am trying my best to do this, but it is really hard.

I try to remember that drug addicts are people, too.  Drug addiction is a serious medical issue, and it involves my help as much as their pain does, real or not.

(Here is a link to the article I referenced:  You Can’t Yelp Your Doctor)