I've seen this term tossed around recently and didn't pay much attention to it. I knew that it was a problem, and had seen the first-hand effects in my resident clinic. Mostly I dealt with patients written off as having chronic pain and now dependent on large doses of opiates. Some patients would come to my office asking me to continue their already existing 240 tablet monthly Norco prescriptions. For most, my reluctance to continue that care plan led them to seek medical care elsewhere, but a select few stuck with me and I worked to address somatic complaints with non-narcotic treatments, wean them off the opiates, and address underlying psycho-social issues. Looking back, it was one of the few things I miss about clinic and developing long-term relationships with patients. Now that my practice as a Hospitalist is episodic, my personal investment in each patient feels smaller.
The White House has chimed in on this issue, in 2011 they published a plan outlining education, monitoring, and enforcement goals. More recently, the White House blasted AstraZeneca's 5 million dollar Super Bowl ad touting a new treatment for opioid induced constipation.
Physicians have been under the magnifying glass also. Just last year a Southern California physician was convicted of murder after several overdose deaths were linked to her loose prescribing habits, which were in turn fueled by greed in a clinic making several million dollars annually.
The thing that really got me thinking was a study presented during a palliative care lecture. The premise was an elderly patient with stage 4 lung cancer and a family member at bedside insisting that the ER doc intubate her loved one. 68% of emergency physicians surveyed responded that performing the intubation would take less time than having a discussion about goals of care.
So, is the traditional bureaucratic response to this problem appropriate? Should we add more education, monitoring, enforcement, data gathering and analysis?
Practitioners in modern medical practice are already saddled with the ever-increasing complexity of electronic documentation, coding, billing, tracking, monitoring, and regulatory oversight.
We need to treat this as a SYMPTOM and not the disease. It is my opinion that physician detachment, fueled by the fire of medical bureaucracy has forced physicians into a position where patient care comes second to the care they give the chart. Time has become a commodity that physicians have to fight for. Gone are the times of the independent medical practice. The onerous burden of administration in medical practice has made us beholden to our corporate masters. Decisions about patient workloads are now in the hands of people with MBAs who know almost nothing about patient care.
This physician disengagement has led us to a place where 68% of ER docs think it would be easier to intubate the dying patient than to talk about it, even though they thought it was the wrong thing to do!
I have seen the same phenomena creep into my practice. It's annoying for me to spend 20 minutes explaining why I think Tylenol and Ibuprofen are appropriate for my patient's pain control after they leave the hospital. It only takes me 30 seconds to fulfill my patient's narcotic wishes with a prescription.
I was hopeful listening to the Surgeon General's remarks today. He talked about plans to address the opioid crisis, and his upcoming report on addiction and substance abuse:
“We’re going to stop treating addiction as a moral failing, and start seeing it for what it is: a chronic disease that must be treated with urgency and compassion…"
One of the tools that emerged to help prescribers is a PDMP, or prescription drug monitoring program. This allows providers to look up pharmacy records online and see if patients are getting narcotics from other sources. In Oregon, the program was so terribly implemented that it was almost not worth using. The time and work required to log in, search, and find what you were looking for was not worth it.
I hope that we can emphasize the importance of supporting physicians in this fight, because it is a valuable one.