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onny D is cupping his jaw with both hands, writhing on the gurney, and pleading with me to give him “something for the pain.” His teeth, those that remain, are a ragtag crew of decay. He’s been popping ibuprofen like candy. Antibiotics no longer help. He needs a dentist, but he lacks insurance and the private dentists he contacted won’t see him without cash upfront. “I’m trying, doc,” he says, as if reading what I’m thinking. “You think I want to be here?”

I don’t know what to think. Looking into his mouth makes my own jaw throb. But I do know that 4 of 5 new heroin users kickstarted their habits by abusing painkillers. Opioid painkillers and heroin were responsible for nearly 50,000 lives lost in 2016 from drug overdoses. In my emergency medicine practice, these statistics have faces, and sometimes these faces have rotted teeth.

Sonny (not his real name) wants what he says worked the last few times he came to the emergency department for dental pain. He’s asking for Vicodin, a combination of the opioid hydrocodone and acetaminophen. It’s in the top five most commonly prescribed drugs in the United States. Opioids — whether it’s Vicodin or oxycodone or many others — have transformed dental and other pain into a moral and clinical cage fight. This struggle is lost in the headlines that blame physicians for the opioid crisis. It ignores the on-the-ground experiences of many of us who strive to do the right thing when the “right thing” is the very thing in question.

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Will the opioid pills Sonny is asking for treat his pain, feed an addiction, or both? Will prescribing it fulfill my moral responsibility to alleviate his distress, contribute to the supply chain in the illicit pill economy, or both? Prescribing guidelines from the Centers for Disease Control and Prevention and recommendations from medical specialties and local hospitals are well-intentioned and necessary. But they do little to address the central anxiety that makes this decision a source of distress for physicians like me. It’s hard to evaluate pain without making some judgment about the patient and the patient’s story.

Sonny tells me his pain is an 11, off the charts on the standard 1 to 10 pain scale. But what really drives my understanding of Sonny’s pain, and my response to it, is the degree to which I believe his story and my emotional connection to it.

In her book, “The Body in Pain,” author and professor Elaine Scarry said it best: “To have pain is to have certainty; to hear about pain is to have doubt.”

I have doubts. And I doubt my doubts. Sonny’s medical record reveals multiple visits to the emergency department in the past few months, always in the heart of the night, for the same throbbing ache. Past treatment has included antibiotics, ibuprofen, naproxen, and opioids, though for never more than a few days.

He shakes off my suggestion of a local nerve block, the preferred remedy to numb dental pain. “They tried that the last time,” he says. “The pain finds a way in.”

Sonny needs a dentist, not opioids. I suggest phone numbers to local dental clinics.

“Called them,” he says. “I leave messages. They don’t call back. The clinics that answer the phone are booked for months.”

I sympathize with Sonny. I sympathize with the overworked dental clinics. That said, every emergency physician has been duped by patients who use the ruse of pain to feed an addiction and divert drugs onto the streets. Decades of experience has created an internal radar for red-flag behaviors that raise the suspicion of doctor shopping — seeing multiple providers in hopes of finding one with a lower threshold for prescribing opioids. But I’ve discovered that my gut instinct is prone to error, again and again.

A good story shortcuts analytical thinking. It can work its charms without our knowledge and sometimes against our better judgment. Once an emotional connection is made and the listener becomes invested in the story, the believability of the story matters less. In fact, the more extreme the story, the greater its capacity to enthrall the listener or reader.

Stories can elicit empathy and influence behavior in part by stimulating the release of the neurotransmitter oxytocin, which has ties to generosity, trustworthiness, and mother-infant bonding. I’m intrigued by the possibility that clinicians’ vulnerability to deceit is often grounded in the empathy they are reported to be lacking.

Sonny’s story isn’t life and death, but it is extreme. His dental plan involves letting his teeth decay and then having them pulled.

“Look at this mouth,” says Sonny. “Is this the mouth of a faker? I used to be a good-looking guy.”

I believe that. He inhabits a T-shirt, an open flannel shirt, jeans, and steel-tipped work boots with the remains of swagger.

The opioid statistics cast a dark and devastating truth, but what good are data against a man with dental pain telling a compelling story?

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I review the statewide prescription monitoring database. Sonny’s name pops up with the same thing that is in his medical record: prescriptions for a few days of opioids here and there. But they are written by multiple health care providers, not one. Such a pattern echoes the activity of someone hunting opioids for illicit purposes. I explain to Sonny that in an opioid epidemic, perception alone can harden into permanent suspicion.

“What about your medical doctor?” I ask. Sonny shrugs. His medical clinic has a strict policy against prescribing opioids, another reason why he’s in the emergency department.

“I’m stuck,” he says. “I know you probably don’t believe me.”

I’m stuck, too.

In emergency medicine, we care for anyone with any problem at any time, and that includes people with secondary motives. Sonny’s story knocks against other stories I heard during that night’s shift. The woman with a migraine and a long history of substance abuse who yelled at us because we wouldn’t prescribe opioids for her migraine. The man claiming low back pain and an inability to walk who jumped off the stretcher and stormed out when we wouldn’t prescribe Dilaudid, a powerful opioid painkiller.

When I consider pain through the lens of story, I recognize that patients may go on the defensive, fueled by previous experiences with medical personnel, and never get the chance to tell their stories. In one report, a sickle cell patient described how encountering the opinions and feelings of medical staff were worse than the pain. In a profession built on the moral precept of “do no harm,” physicians’ biases and judgments can devalue patients and push away people already isolated by their pain.

My relationship to Sonny’s pain deepens as I learn how he supports his young family by juggling two jobs. He works at a warehouse until 2 a.m. four nights a week. His wife came and waited with him in the emergency department for a few hours tonight.

I ask Sonny how he could have been sleeping in the waiting room, his jean jacket pulled over his eyes, and then a few minutes later in the examination area be rocking in pain. Before his wife left to get their kids off to school and head to work, he says she gave him some ibuprofen that took the edge off his pain for a bit.

I’m curious how he endured the pain yesterday and the day before. And what about tomorrow? He lowers his head, assumes a posture of confession. Sometimes he buys Vicodin and other opioids on the street when the pain becomes unbearable.

Finding clarity is hard when deaths from opioid overdoses exceed those from gun violence and motor vehicle crashes combined. Physicians, especially emergency physicians, have been called out as culprits in the opioid crisis. Practice patterns vary, but reports show that my colleagues and I prescribe opioids in a responsible fashion — short-acting formulations at the lowest possible dose, and only for a few days.

Sure, alternatives to opioids are ideal. Examples include regional nerve blocks, disease-specific therapies, and an integrative approach to pain. They aren’t risk free, but medical decision-making is always a wrestling match between risks and benefits. With Sonny, however, I can’t dodge the opioid question.

I feel uneasy. Overdoses and substance abuse are a devastating part of my practice. But without a dental appointment in sight, Sonny will be back, incurring the financial burden of another emergency department visit. Or he’ll find what he needs on the street.

If Sonny comes to the emergency department in pain and goes home in pain, what does that say about me? I’ve perpetrated a grave moral harm. Not only because I provided substandard care, but because I didn’t believe his story and I didn’t fully trust him.

I finally decide to prescribe a few doses of Vicodin for Sonny. My reasoning isn’t easy to grasp. I’m responding to his pain directly, but also to the story of his struggles, of which the pain is a part. I realize that what I am doing might tag me with a red flag. But indifference isn’t a virtue, and writing prescriptions for medications that haven’t been effective doesn’t feel right either.

Relieving pain is a basic human gesture. Yet in an opioid crisis, a simple case of dental pain becomes a source of frustration and mental exhaustion. I can’t say my choice was right. Uncertainty rules when stories are subjective and open-ended. But uncertainty also suggests possibility. Story is the ground where clinicians and patients meet, where they can become more accountable and recognizable to one another. Responsible and compassionate pain management requires fluency in both science and story.

Jay Baruch, M.D., is associate professor of emergency medicine and director of the Medical Humanities and Bioethics Scholarly Concentration at the Warren Alpert Medical School of Brown University in Providence, R.I.

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  • I don’t understand why this is even an issue.

    The first paragraph tells everyone involved that the guy is an addict: no teeth! He has been an addict for a long time; that is why most of his teeth are gone. The patient then confirms that he’s a drug seeking addict a few paragraphs later, by refusing the nerve block and insisting on opioids.

    So the only question is should you feed his addiction? The answer is “no” and there is no ethical issue at all. He’s tricked you into thinking there is an ethical issue by claiming that there is pain. Horrible pain. Eleven on a scale of ten! Shades of SPINAL TAP (the movie, not the procedure).

    • This amount of hand-wringing over a few Tylenol/codeine seems absurd. Your role as an ER physician is to treat the injured person at that time and to recommend them to follow-up with other providers. If this person didn’t have the resources for their needed long-term treatment, it seems that your responsibility is clear. Treat the patient for the issues that brought them to you, in this case, horrible dental pain. What’s he’s done in the past isn’t “drug seeking” as one of your commentators stated. Instead, he is a desperate an in a terrible situation. You made the right call.

      The larger issues of potentially creating “addiction” from one or two ER visits is not really even your concern. In fact, it seems quite paternalistic for you to even contemplate withholding needed medications due to an abstract, unquantifiable risk of creating an issue with addiction.

      A Cochrane review of the most recent literature has shown that less than 2% of people who used pain medications legitimately go on to use them inappropriately. This is also reported by a study by Fishbain, et al. Translated, this means that 98 out of every 100 patients you see will have no problems with addiction, but do need pain medications for whatever urgent situation brought them to you.

      There is also the issue of accountability. Should a patient, who you treated properly for acute pain, choose to abuse their medications, that is not your responsibility. What someone might do, later on, shouldn’t stop you from treating pain appropriately. In fact, having the ability to relieve intense, acute pain, but withholding it, is akin to torture. Is that how the health care system of the world’s most advanced nation is going to treat its citizens? Everyone is going to be treated as a potential abuser, no matter how responsible, respectful, and properly they take their needed medications? How will such an approach really help any of the situations you’re trying to address? The net affect of such a policy
      Will simply force patients in pain to find pain relief from illegal sources, since legal and legitimate places are denying them relief. This will only increase overdose statistics, rather than addressing them.

      And if treating everyone as a potential addict is going to become our syandard of care, then we need to immediately take away everyone’s car keys – because some people who abuse alcohol drive while intoxicated and kill themselves and even others (something people with addiction rarely do). We should use the same logic that is being applied to pain medications But for some reason (tax income?), in this area, we don’t punish the vast number of law-abiding citizens for the wrong actions of the few. Applying the same logic again, we should never even allow anyone to have an alcoholic beverage, ever, because there is potential that they might become addicted.

      Treating people as risks for behaviors that only a very small portion of the population does is a terrible policy. In fact, exceptions always make bad laws. Create intelligent policies that cover the majority of the population, and allow adults the courtesy of trusting them until and unless they give you a reason not to.

      Treat the patient that is in your ER.

      Journal Pain Report: http://www.tandfonline.com/doi/full/10.3109/15360288.2015.1136368

      http://idhdp.com/media/530765/negative-outcomes-of-unbalanced-opioid-policy-supported-by-clinicians-politicians-and-the-media-1.pdf

  • People with chronic pain often believe that only opioids will help their condition, and prescribers often are reluctant to provide long term narcotics for non malignant pain. I know because I have been there, peering at old records and listening to the patient’s story, looking for reassurance that they aren’t potential addicts. Reading this article makes this difficult patient problem seem like a black and white decision: Do I write a script or not? More often, there are a number of ways we can step back from the prescription dilemma, by recognizing other helpful strategies. First and Foremost, the clinician needs to be educated. Chronic pain syndromes are usually not well managed with analgesics alone. The evidence based literature will show that they provide a small amount of relief, versus placebo, and are associated with comorbidities and side effects. A lot of patients will howl at me for saying this, but the evidence is there to support this statement. Moreover, if i prescribe opioids to a patient who cannot show a functional improvement in his activities of daily living as a result of the analgesia, I have achieved much. This necessitates getting a very thorough history of just what a pts baseline functional status is. How long is the pt out of bed, how far can they walk, are they able to drive? To work? to pursue physical recreation or vigorous activity? If their pain prevents them from many of these things, then I always urged physical therapy and an exercise program as a “must do” add on, to a short term trial of an opioid. Does the patient have knee pain, and is grossly overweight? I think it is appropriate to insist they enroll in a weight loss program, because we can show them the robust evidence that weight loss can improve knee and back pain. If I start a patient on long term opioids, and I neither return them to a higher functional status, nor improve their underlying condition, while exposing them to the deleterious risk of addiction, I have caused harm.

    The days of patients showing up and demanding opioids as the ONLY acceptable means of managing their chronic pain are over. Clinicians need to use a broader spectrum of modalities to help people with chronic pain, including psychiatric care. When patient’s balk at this multifactorial approach, it is a red flag that the patient is a chemical coper, and I would prescribe only with great caution.

    • The evidence based literature will show that they provide a small amount of relief, versus placebo, and are associated with comorbidities and side effects. A lot of patients will howl at me for saying this, but the evidence is there to support this statement.

      Please provide your evidence for this statement.

    • Here is a recent meta-analysis, on treating chronic back pain, a condition for which clinicians employ a lot of opioids, with very little reassurance that it is a reasonable Rx plan, or “best practice”. Please understand, I am aware of the paucity of good research on long term opioid use for chronic pain syndromes, but what I read does not comfort me, in the same way that opioids provide insufficient comfort to most chronic pain sufferers. We need better tools if we are going to have better outcomes.
      https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2522397

    • To everyone reading these comments, please note the complete silence coming from the poster above. After making egregiously incorrect statements, he fails to provide the evidence he swears he has. Meanwhile, I have provided quality links to prove my statements. Those who make these sweeping statements have absolutely no evidence to back them up, no matter what they say. It doesn’t exist.

    • ACH, please forgive my post, which was directed at gkgk.

      But since what you stated is true, you cannot claim that there is no long-term benefit to chronic opioid therapy for intractable pain syndromes. The evidence we do have suggests that they do provide a crucial benefit in some cases. But as there are virtually no long-term studies for either of us to state, the judgment of our experienced physicians, along with their patient, must be the final arbiter. Not the hospital board, not the insurer, not the DEA, not the pharmacy. The physician and the patient together.

      Personal responsibility seems completely absent in this entire debate. If I choose to overuse or abuse pain medication and develop an addiction, I cannot see how that is the responsibility of the dentist or physician who prescribed them to me for a legitimate reason. Why are we holding physicians responsible for the actions of people over whom they have no control?

      The more important issue though, is that physicians, through their training and experience, should be trusted to make decisions, along with their patients, using the medications and therapies at their disposal. Our government does not need to be checking up on each doctor to the degree that our poor ER doctor has to spend an hour checking databases, coordinating with multiple agencies, wringing his hands trying to decide if he can give two Vicodin to someone in a very sad situation.

      Too many entities are involving themselves in the practice of medicine. What is the point of attending medical school, earning this difficult and demanding degree, and learning – through years of experience – which therapies work in which cases, if they’re going to be hounded by regulatory agencies, and their instructions denied by the pharmacists whose task is to facilitate their instructions?

      Theories about the causes of addiction abound, but no one truly knows why out of 100 people, two might choose to abuse substances. But we should not deny treatment to the 98 people who are in need of pain care because of the fear that two might choose to abuse these substances. (Fishbain et al 2008)

      Legitimate patients cannot be held hostage due to the negative actions of a few. And while the narrative sounds as if we are enduring a tremendous epidemic, the truth is about 15,000 people overdosed with substances last year. And while that is truly unfortunate, I don’t know that it rises to the level of an epidemic. More people died of alcohol abuse – 88,000, as reported by the CDC. 440,000 people suffered preventable medical errors. 15,000 or more died from ibuprofen and other NSAIDs, and over 100,000 more were hospitalized due to cardiovascular and G.I. related morbidities from ibuprofen.

      We must refuse the media hype and look at this entire conversation in its proper context.

      The true cause of overdoses is the flood of illegal Fentanyl and it’s analoges, frequently cut into heroin. Their potency is terrifying and unregulated. If we want to stop people from dying, this is where we should be focused. Not the poor gentleman in the ER who needs some pain relief because he can’t afford dental care.

      That we are even debating this is inhumane.

    • http://onlinelibrary.wiley.com/doi/10.1046/j.1526-4637.2002.02043.x/full

      Says kind of the opposite. I guess we can agree that further studies might help prove or disprove their effectiveness long-term, but ultimately, that is still a decision that a patient and their physician should make, not government policies based on unreliable statistics. There isn’t even a standardized procedure from one county to the next that is reliable for collecting or analyzing deaths.

  • I am wondering how you came up with 4 out of 5 people using HEROIN users started with opioid abuse? Where is your facts?? Where are the long term studies to support your claim??? Unfounded statements like this is what causes thousands of chronic pain patients like myself who suffer with rare and dibilitating diseases to be looked upon as addicts. I made the mistake of going to one local hospital due to a massive pain flare. All I wanted to was non steroidal inflammatory shot. My BP was very low, which is what happens when my pain becomes out of control instead of rising like all the rest of the pain population. Instead, the physician treated me like an addict, tried to give me a high dose of opioid shot in which I refused bc I knew I would stop breathing bc my BP was to low. The nurse lied to me and said the Dr has went up to another floor of the hospital and she didn’t know when he would be back! I made my husband vet the wheelchair so i could leave. Passing the nurses desk, there stood the ER doctor who had seen me! I was crying bc of the pain and went back home the same way I came. In massive pain, crying and just begging God to take me home! I reported THAT doctor. Just because other patients go there seeking medication due to their addiction doesn’t mean ALL patients do. I suffer with Adhesive Arachnoiditis, 6 Tarlov Cyst inside my lumbar/sacral and RSD/CRPS. All 3 diseases have NO cure and Adhesive Arachnoiditis has been quoted by one physician as the pain being like stage 4 cancer without the release of death.
    This ER doctor refused to even look at my medical records that were on file! He had his mind made up as soon as I got there.
    Now you tell me where does THAT leave patients like me??
    Do NOT make statement like you have here without proof to back it up!

    • Donna if you read the article he gave you the EXACT data that the Center for Disease Control and Prevention (CDC) published and I can tell you it is true and has been for a LONG time. MOST heroine addicts start with prescription drugs and then move up the line mostly due to cost and access. Initially, they get their fix from their doctor then they buy them on the street then eventually the cost of prescription drugs is too high so they resort to street drug at 40% of the cost but with 300% of the harm and from there it is off to the races to see who ODs first
      Your analogy is EXACTLY opposite of the article and most of our experiences. In our experience, we see patients UNLIKE you how do not want narcotics only NSAIDS we see opioid seekers who have all the reasons that NSAIDs won’t work from allergic to them to ulcers to nausea to they don’t work
      So suggesting that the article isn’t perfectly in align with your experience is opposite.
      Our issue is HOW do we know when someone asking for pain meds is real and in pain or just shopping for tonight’s fix? We do NOT make assumptions unless the person has the look of a druggie or has a medical record as long as the phone book (do they still have those anymore)
      The issue is using the right drug that works for the purpose we need and NOT having enough drug options that don’t cause long-term problems
      If we use NSAIDs they are not effective enough and or cause gastric bleeding even with antacids and or PPIs. If we use narcotics then we open the door for the person susceptible to addiction to getting started on a lifetime road to hell. NOT everyone has the addiction “gene” many people can tolerate narcotics with NO high and NO addiction. What we need are more options but we don’t have any and there is none in the pipeline that will do any good any time soon
      Sorry about your many medical ailments but the issue of narcotic abuse is real and really doesn’t affect you since you don’t use them or want them.
      Dr Dave

    • Dr. Dave,
      I do use a low dose opioid for my chronic conditions that do help to an extent. I DO understand what doctors do face as I’ve seen it happen in the ER with an addict (the attending nurse told me) as the woman was screaming for drugs. I know it isn’t an easy job by NO means at all, but my point is to not assume all patients who are in pain are addicts. Perhaps a drug test on patients who are wanting opioids to see what is already in their system? As for the CDC stats, as I said, there have been NO long term studies to back this up. However you physicians can account to what YOU see in the ER. I do commend all physician’s who do look at each patient as individuals and not see them all as addicts. I know it isn’t easy at all and I honestly do not know how some ER doctors can handle the irate addicts. I and MANY other chronic pain patients like myself have been treated like addicts due ro rhe fact of being in a massive pain flare that we could not get under control. Needless to say there is NO easy fix or solution for this problem. As pain patients who suffer with rare and dibilitating diseases, all we ask is to be heard and helped, especially with pain medications being taken away from most Chronic Pain Patients due to this opioid epidemic. More will be forced to go to the ER bc of the pain.

    • “4 out of 5 people using HEROIN users started with opioid abuse”

      Donna, this was the result of a 2013 study by SAMSHA. What people, such as Dr. Dave, are not aware of, however, is the study looks at the association of NON-MEDICAL pain-reliever use and the initiation of heroin use within the US. In other words, this study’s participants ABUSED/MISUSED prescription opioids for the “high” and NOT for legitimate medicinal reasons.

      Even more interesting, the large majority of these participants obtained their prescription opioids in an illegal manner (stole them, bought them off the street, family/friend gave it to them, etc). This tells us that the participants within this study ALREADY had adopted the behavior attached to most addictions (manipulation, theft, etc) PRIOR to ever receiving a prescription opioid for legitimate medicinal need.

      99.9999% of these participants most likely abused alcohol in their youth. In fact, studies have found that over 90% of addictions actually begin in the early teen years – for most in their teens, this is many years prior to ever needing a prescription opioid for a legitimate medical reason. Most likely, the same participants within this study was introduced to alcohol as their first intoxicating substance of abuse.

      What many people do not understand is that much like eating disorders are not about food, addictions are not about the substance(s) of abuse and addiction. What I mean is the substance of abuse is merely the main symptom (often, a very deadly symptom) for something that is EXTREMELY complex in nature – known as addiction.

      The act of sex is not the “cause” of sex addiction. The act of gambling is not the “cause” of gambling addiction. The act of eating is not the “cause” of food addiction. The act of shopping is not the “cause” of shopping addiction. The act of ingesting an alcoholic beverage is not the “cause” of alcoholism. The root cause of addictions will differ for every addict, but the act of ingesting a substance is rarely the cause of drug addiction. (*See note*)

      Genetic predisposition, personality traits, mental illness, the environment in which one is raised, peer pressure, traumatic experiences can all contribute to the development of an addiction. Deep down in every addict is one who might have been raised in a very ugly environment, might have suffered some sort of emotional or physical trauma, might have an undiagnosed, untreated, or undertreated mental illness, or might simply be self-medicating some deep emotional pain.

      (Note – physical dependence and addiction are two separate issues. Physical dependence can happen without the presence of addiction while addiction can happen without the presence of physical dependence).

      http://archive.samhsa.gov/data/2k13/DataReview/DR006/nonmedical-pain-reliever-use-2013.pdf

      https://consumer.healthday.com/mental-health-information-25/addiction-news-6/addiction-starts-early-in-american-society-report-finds-654435.html

  • This article does a very good job of demonstrating the dilemma. Giving the man a few Vicodin tablets is almost benign even if he was simply drug-seeking.
    I do agree with those writers who suggest the next day call to a dental clinic since all MDs’ calls are returned, if not taken at the moment.

    I recently had an absessed molar and the dentist gave me an antibiotic and a scrip (Rx) for 600 mg. of ibuprofin to be taken with Tylenol/acetaminophen bought over the counter. Since the antibiotic was prescribed for every 8 hrs, the Ibuprofen every 6 hours and the acetaminophen every 4 hours, I had to set up a written schedule to keep track of all this. I’m retired and have the time to do this. Can’t imagine how a person with less time or fewer math skills might make out with this regimine.
    The NSAID plus acetaminophen did manage the pain just fine until the tooth got the next level of care.

  • As retired physician assistant who has treated hundreds of drug abusers in the past, it find it hard to weed the stories. I I think that sometimes it boils down to Common Sense and a few judicious calls to other main pharmacies to look for a pattern.
    It is interesting that since I have retired and had two back surgeries three shoulder repairs and some partial colectomy, and severe gastritis from trying to cover my pain with nonsteroidal anti-inflammatories. Interesting to be on the other side of the fence I take approximately 90 Percocet every 3 to 4 months, but feel like a drug abuser each time I ask for a refill. I certainly have been treated for over 2 years like this and I’m not any closer to being addicted. It’s interesting that sometimes you find yourself on the other end of the fence looking in

  • As a mid-level practitioner, I certainly have my own concerns about opioid prescribing. However, I also happen to have severe cystinuria and frequently get kidney stones. Unfortunately, cystine stones do not show up well. I am fortunate that I rarely need emergency department visits for my stones, but have, in the past, been accused of “faking” my pain because stones don’t always show up adequately on CT, KUB, or US. I know other cystinuric patients around the world with similar stories and the number of negative emergency department experiences far outweigh the positive, as a general rule. There is obviously no simple answer. Sadly, the opioid crisis sometimes has a significantly negative impact on patients with legitimate pain.

  • You can either be humane and help legitimate people in pain or live in fear the DEA is coming for you license. Not providing adequate pain relief to legitimate, responsible, persons is barbaric. To make things worse, now surgeons are afraid to treat post op pain. I’ll bet the Doctors get the needed treatment. Sad state of affairs. No wonder the borders are overflowing with heroine and fentanyl. You’ve created a new and desperate market. Patients in pain are considered acceptable collateral damage in the so called, “War On Opioids”.

    • How do we know the difference????
      I know of NO doc who cares at all about the DEA and or their license for a legitimate pain patient the question is HOW do we know who is in pain and who is faking it for access to narcotics? About 35 years ago we had a patient come in with a large neck abscess (I am a head and neck cancer surgeon) and was claiming to be in significant pain. What I saw I agreed that he very well could have been in extreme pain. So we wrote scripts for pain meds and antibiotics and scheduled him for surgery in 3 days. Needless to say, the patient never showed up. Interestingly enough 2 YEARS later he shows up with a totally new name and ID with the same identical neck swelling. This time my staff realized that this was SO unique that it might be the other patient. So we dug up the other patient’s records to find out that he falsified either one or both IDs to obtain narcotics (a Federal Felony). While we did the initial workup we called the police, they showed up cleared the waiting room in case he got violent (which he did) and arrested him. After the DA looked into it he had been duping every surgeon, physician, clinic, and ED and even dentists in a 25-mile radius for YEARS to obtain narcotics. He was convicted of fraudulent manipulation to obtain narcotics which came with a 12-month jail sentence.
      So the point is; how was I supposed to filter him out from the other patients who ARE actually in pain for pain meds? BTW he was actually NOT in pain the situation was a chronic abscess and wasn’t causing any pain but only looked strange enough to warrant sympathy and concern from an otherwise caring healthcare team
      The whole article is about this issue. Just because the guy’s teeth were a mess doesn’t necessarily mean he is ANY pain. Yes based on the spin of the article it was decided he was in pain BUT he very likely could have been in NO pain and drug hunting.
      I was instrumental in getting a law passed in PA that states that positive ID could be requested by the Pharmacist before a narcotic drug could be dispensed if the prescription states so. Basically, the name on the script has to match the ID or no go. That prevents script selling. Also, we would add that all prescribed drugs had to be filled. This means that if the person is given both an antibiotic and a pain drug and then tells the CVS only to fill the narcotic then NO drugs would be filled at all
      Laypeople have NO idea what we go thru to filter out the needy from the druggies
      Dr Dave

  • Why didn’t the author pick up the phone and call one of the free dental clinics to ask for the patient to be squeezed in? It would have taken less time to make an appointment than it did to write this article and would have fixed the root of the patient’s problem (which both solves the opiate question and is also the best care for the patient).

    • You assume that they are that plentiful and that they actually have other non-pressing patients that can be moved in order to treat him (how would you feel if your procedure was canceled because they took him instead). The issue is who is going to pay for them to do the work. Clinics are not free they are Welfare based and if the guy doesn’t qualify for medical assistance then they won’t see him at all unless he has cash. Two issues one is how to afford care and two; is he legitimately in pain or drug seeking.
      Also, you really expect an ED doc at 2 AM to call around to find a Dental clinic???? The ED is not Social Work Central it is a care provision facility for EMERGENT need patients. I bet that in excess of 50% of the patients that go to an ED are NOT emergent in any way shape or form
      This guy SURELY was in pain at 3 PM and 9:30 AM but like many, they wait till the sun goes down and then to the ED for pain meds THAT is not emergent need
      Dr Dave

    • I don’t assume any of those things. A phone call from a treating physician can work wonders for access, even at difficult to get into clinics. I don’t expect the doctor to call at 2AM. I expect that if this patient were weighing heavily enough on his mind to write this article, he could have taken 5-10 minutes the next day to call a clinic. I’ve done this many, many times for my patients, even though I “don’t have time”. It ends up being one of the most rewarding things I do.

      Whether you like it or not, patients often have social issues interwoven with their medical care. Those social issues affect their health and we thus have no choice but to interact with those issues, regardless of the setting. But honestly, this is what I love about medicine – I have so many ways to help make patients’ lives better. It can be medication, it can be a referral, it can be a phone call, it can be a sympathetic ear. When we lose this interest in the patient as a human being, we lose why we went into (or should have gone into) medicine.

    • BB
      I like you agree that there are lots of solutions and that many of the non-clinical ones are more valuable to the patient then the clinical ones. The call the next day is going to help pay the bill how?
      The issue is the patient is broke how is getting a call to ANY place going to generate the payments that the Dentist deserves for treating the mouth full of mess?
      I didn’t get from the article that this was an isolated issue with no scheduling for his needs I got it that this was a generic national issue with lots of people unable to come up with cash for teeth and so they rely on the ED for round after round of pain meds
      Same goes for Podiatric care (unless they are diabetic) and other issues that are simply not covered by Medical Assitance or commercial insurance. We as providers can only fix the obvious the rest is not on our desk regardless of how much we want to place them there and be helpful unless we write checks to assist these folks how are we to resolve this issue on a more than one case basis?
      The issue goes WAY back to the era of employers paying for care for employees so that employees no longer to budget for medical needs. This patient has other priorities that he budgeted for and left the door open for teeth. Back in the pre-1960’s people budgeted for medical needs. The current model of adding more and more to the welfare or third-party system only requires that more and more cracks will open that leave people to fend for themselves. Had every person been born with a SSI number and an HSA for which money could be added throughout their whole lives pre-tax maybe this guy could tap it for the $1k++ to get his teeth out but we instead said/say don’t worry about it someone else will handle your medical costs so we now need to add in Dental to the other additions to make room for this crack in the entitlement armor.
      Dr D

  • From a Stroke, I’m prescribed Morphine. I’m in constant pain and my doctor wants to slow down and back off the dosage so I don’t get hooked but isn’t offering any other alternatives. I’ll just be in pain. What’s the difference???

  • A few questions:
    1. Why was this patient not medically screened? EMTALA requirements would have been met with an MSE and there is no need for life or limb saving treatment in this particular case. All that really needed to be done was give a list of resources for dental care, and any social service related resources. This is not an appropriate patient to be seen in the ER. Pardon my French, but this repeat offender needed a hard ass approach, or the behavior will continue if its behavioral in nature. If its a system or resource problem, then again, this person needs to be clearly and firmly redirected to the right resource to resolve the root cause of the problem. It is not the responsibility of the ER to deal with this problem beyond any life or limb threatening issue.
    2. What are the statistics and facts by provider on prescribing? Ex. Number of pills or type of pills and associated diagnosis. ? I would like to see the statistical breakdown on prescribing practices using each practitioner’s DEA/pharm record. I am not inclined to believe that the majority of the US health care community is participating in pill mill practices. It is more likely a few bad apples and a few bad pharmacies, along with the black market, who have created a mess, and now they need a scapegoat. So, since we are being scapegoated on this, show us the facts. From my observation, my colleagues do not engage in practices that would not pass evidenced based standards of assessment and treatment for pain. Why are we allowing NON-medically trained bureaucracy, media, individuals, etc. tell the trained professional when they are right or wrong in the decision making process? We can reflect on the trend when JCAHO got involved, and teaching methods of pain as the “fifth vital sign” and pain as “whatever the patient states it is” put pressure to always prescribe to the point that the patient would give a zero on the pain scale answer. Obviously, this is not what a trained medical professional would support for various reasons, but we don’t know better than they do. Do we? The medical community needs to unite on this and refuse any accusations that is not clearly supported by the data.
    3. What does C-Fentanyl, a substance used by chemical terrorists, have anything to do with the medical community? The answer is nothing.
    4. Which practices and professions prescribed fentanyl? Is not fentanyl used primarily in surgery, such as eye surgery? Who in their right mind would prescribe a drug that in subtle amounts requires airway management? I don’t know anyone who does this. Please elaborate and provide their names and DEA numbers/pharm record. The accusation sounds suspect.
    The doctor who gave a few pills in this story is not a bad doctor or making a decision that would take his DEA license away. Give me a break. However, he is not helping any behavioral aspect of the problem as the patient should not even have passed an MSE and would not likely have paid the $ for the ER level service, and thus would have left on his own accord, so he brings this on himself when he could basically not deal with this at all, and he would be within his right as an EMERGENCY physician. If time allows, why not call the primary care doctor and verify what the patient is telling you and document it? If your administration has an issue with that, they need to consider how their pressure on staff result in dysfunctional and expensive behaviors, and the primary care doctor/clinic needs to be aware of what their patients are doing and saying about them, which may also not even be true. When you get the facts, you can then confront the patient better on the issue.
    So, a great deal of energy and time can be spent on a single ER visit/type of patient. But once again, MSE exams can be very helpful in filtering out these distractions so that staff can properly be focused on real emergency care and medicine.

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