American College of Physicians: Internal Medicine — Doctors for Adults ®

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Monday, September 17, 2012

Putting a stop to drug seeking behavior

Chronic pain and how to treat it is a big topic in the medical world right now. In one study, 39% of patients coming to the emergency department with pain reported an underlying chronic pain syndrome. Prescription drug seekers can overlap with patients who have true acute pain and need relief. We want to provide pain relief, yet we know that many of these prescription drugs get diverted and used for non-medical conditions.

After marijuana, prescription drugs are the most commonly abused drugs of 12th graders. More than cocaine, meth or other drugs that we worry about, kids are getting into their parents' medicine cabinets. These prescriptions are getting into the wrong hands.

Doctors and pain clinic owners in three states were charged today with distributing prescription drugs in Kentucky, an area that is rampant with abuse. One doctor prescribed more than 125,000 Oxycodone pills from September 2006 until July 2011. And in Florida, several doctors were arrested this week for running a "pill mill" and pocketing millions of dollars.

Those are the egregious cases and jail is the best place for these physicians.

Most physicians, however, are caught in the difficult role of providing adequate pain relief for acute and chronic conditions and balancing that with the addictive potential of narcotic medications.

Most emergency department physicians (and nurses) and every primary care physician who has a few years of practice under his or her belt can spot a drug seeking patient. The tall tales are absurd and follow certain patterns:
"I lost my prescription." Variations on this theme are that the pills fell in the toilet, were eaten by the dog, hamster or (insert animal here).
"The pills disintegrated." The pills got wet, got mixed with noxious substance, the container opened and they got dirty.
"I'm allergic to other pain relievers." This one is usually the new patient who gives the history of trying everything you mention, but only Vicodin or Oxycontin or Demerol will work. Period.
"My prescription was stolen." Common tale. Lots of theft, it would seem.
"I have recurrent (insert condition here) and need the medication on hand." (kidney stones, bowel obstruction, migraine headache, back pain, menstrual pain, sickle cell anemia...)
"My pain is a 10 out of 10." All the time.

Chronic pain is truly debilitating and we doctors want to relieve pain and help patients get back to their normal lives. But we can be the problem as well as the solution. Each narcotic prescription we write has the potential to harm as well as help and we have to be conscious of our own prescriptions and how they are used. My wish would be for a strong pain reliever with no side effects that is not addictive. Problem solved!

This post originally appeared at Everything Health. Toni Brayer, MD, FACP, is an ACP Internist editorial board member who blogs at EverythingHealth, designed to address the rapid changes in science, medicine, health and healing in the 21st Century.

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2 Comments:

Anonymous Anonymous said...

Thanks for writing this. As someone who has recently been diagnosed with Lupus, I've been using narcotics because I have yet to find the right NSAID to control it. I'm constantly afraid of being labeled a drug seeker, and was terrified that moving to a new state would result in not getting a new prescription. Luckily, my new doctor was sympathetic, as I have to wait a month now to see my new rheumatologist for the first time so that I can resume my search for an effective non-narcotic treatment.

In the meantime, I am very protective of my pills. They stay in a dry place and out of sight. Perhaps, given how important pill storage can be, there should be better education on this. I rendered half a bottle of pills less effective by cutting them all in half at once, for example.

I completely agree that more effective drugs without addictive potential would be of great benefit. Until then, we'll continue to have patients, like myself, who resist taking their medication for fear of becoming addicted. I can't tell you how many days I suffered instead of taking medication. Doctors should be aware of the stigma of using narcotics, and should initiate these discussions with patients who are avoiding their medication.

September 17, 2012 at 11:59 AM  
Anonymous Suzanne J. Baskin said...

As an RN with 34 years of nursing experience in different areas, I believe that the education of physicians and all health professionals is essential in chemical dependency, addictionology no matter what specialty is. A surprising number of seniors are addicted. I worked in the field of chemical dependency for six years, both in detox and the other treatment aspects. I believe it would help if every residency program required every physician to become an addictionologist before they are out into private practice. I have read medical articles all of my life because my father was a physician and I have interest. I read this site often just to learn. Addictions are pervasive in our society, but I see very few educational articles on this for internists. I know the percentage of addictions are very high that primary care doctors see. It can be very hidden and not show up in labs for a long time, as I have been a recovering alcoholic and also abused benzodiazepines at times years ago and have been in 12 step programs since the mid 1990's. Education is the key in dynamics of addiction, as well as detox. I think one of the best resources are Hazelden treatment centers in Minnesota. Actually the success rates are high, simply because no clinical studies can be done in 12 step groups as they are anonymous. I have seen so many people change their lives for the better. You may not believe it but so many patients do listen to primary care doctors. Thank you for all that you do.

September 20, 2012 at 2:01 AM  

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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