The attorney general of Oklahoma recently charged a doctor with second-degree murder in the overdose-related deaths of five of her patients. In describing these charges, AG Mike Hunter said:
“Nichols prescribed patients, who entrusted their well-being to her, a horrifyingly excessive amount of opioid medications. Nichols’ blatant disregard for the lives of her patients is unconscionable.”
Horrifyingly excessive. Those words stopped me in my tracks because they could easily have described the first time I prescribed opioids on my own.
I’m starting my career as a doctor as the opioid epidemic escalates in the U.S. It puts me in the middle of wanting to honor and treat the pain my patients tell me they feel while sometimes having to count what’s in their prescription bottles to verify they are taking the prescribed dose and not more.
Practicing medicine means being part of the opioid police, while, at the same time, having little guidance on how to effectively treat pain. So I worried: Was I underprescribing? Was I overprescribing? And would this trial and error ever get easier?
The first time I prescribed opioids, I misread my patient’s medication list and accidentally ordered a dose that could easily have hurt her.
“This seems like an unusually large dose of oxycodone,” said the inpatient pharmacist, who paged me to double check the order.
My patient had a long history of opioid abuse, so I knew that she had developed a high tolerance. She needed a higher dose to manage her pain, and my intention had been to help her do that.
I remember learning two things about pain in medical school. First: Pain is effectively the fifth vital sign, and needs to be taken as seriously as a spike in temperature or drop in blood pressure. Second: Each opioid medication is metabolized differently. I remember learning the relative strength of each analgesic in terms of its morphine equivalents.
This was supposed to help me compare apples to apples when it came to prescribing.
I logged onto her records to compare what I had ordered with what I had written down on the patient’s medication list. “Oh, my God,” I said to the pharmacist. “Yeah, this is a lot.” I profusely thanked him and lowered the dose to one I hoped would manage her pain.
I didn’t catch my own mistake because tolerance felt like a moving target — I was still learning how much was too much, and, unfortunately, how little was too little.
Soon after, I had a patient who was dealing with addiction and had infections in his legs that required someone to change his dressings every day. He was in such a fragile state of health that I worried about sedating him too much with opioids. Thinking about my overprescribing mistake, I decided to go with 1,000 milligrams of Tylenol, which is equivalent to two extra-strength over-the-counter tablets, hoping it would do the trick.
It did not.
The next morning when I made my rounds, this patient cursed at me, telling me how much pain I had caused him, asking me if I knew how it felt to have the skin peeled off my legs. I felt horrible that I caused my patient so much suffering.
But he was right — I have never experienced that type of pain. I was trying to spare him the sedative and addictive effects of opioids, but in doing so, I made a choice that didn’t address his actual issue: pain.
I chose Tylenol because I was in the first few weeks of my residency. I was afraid of hurting my patient. Prescribing an opioid seemed riskier than prescribing Tylenol.
My training was to use morphine equivalents, but I’ve never taken morphine. It was like trying to describe the way fruit tastes relative to an apple without never having eaten an apple.
This is what I mean when I say I feel like I’m stuck in the middle trying to treat a person in pain while not feeding an epidemic that often leads to death. The guidance for other illnesses is more defined — I’ve never had a heart attack, but feel confident I could treat someone based on what I’ve learned and seen. With pain management, it’s not that clear.
I promised to get my patient something a bit stronger for his next dressing change. But what? Looking for assistance I tweeted out :
Med friends–Any helpful guide for premedication for dressing changes? Or appropriate meds for dif types of pain in general? #meded
— Jennifer A Okwerekwu (@JenniferAdaeze) August 10, 2016
No one responded. I was surprised.
Trial and error. In managing pain, finding that middle ground is all about trying, and possibly failing. When the goal is to treat patients in ways that don’t foster addiction, I’m left wondering: How many patients’ lives have been destroyed and how many medical decisions have been questioned by a mode of practice that is such a shot in the dark?
As I begin to treat psychiatric patients exclusively, I’m actually relieved that I won’t have to deal with prescribing opioids that much anymore. But, I’m aware — and sad — that the fallout of the opioid addiction epidemic is what I will face every day. So pain won’t be that far behind me.