I have come to dread the fight that ensues upon discharging drug seeking patients. I prescribe Ibuprofen for a sprained ankle. The patient becomes furious, threatens to call Channel 5 News or Bart Durham, a local attorney with sketchy TV ads- you know the type. Depending on the situation I either hold my ground or acquiesce to the pill-popper’s demands. Call me immoral but sometimes you just can’t fight anymore. Then, at the end of the day I slink out to my car ready to attack the attacker who has surely slashed my tires in this drug-seeking dispute. I mentally note to intensify my Jillian Michael’s DVD workouts to better prepare for these types of situations. They don’t teach you this in school.
As a nurse practitioner I am painfully aware of the prescription drug abuse problem in our country. “What are you going to do about my pain?” and “The only thing that works for me is the thing that starts with a ‘D’…yeah, Dilaudid, that’s it” patients often say to me with a sly look on their faces. Too bad our discharge instruction program doesn’t come equipt with a “dilaudid dependence information” handout. Although most patients are not malingering, others are well aware the pain control is a hot topic in medicine and carries potential professional implications for me as a provider.
State legislators are beginning to recognize this problem. Not necessarily on the level of the medical provider, but in an effort to curb deaths related to prescription drug abuse and overdose. Last year Washington State implemented strict policies on painkiller-use. In treating flare-ups of chronic pain, ER doctors are directed to consult the patient’s primary care provider before handing out a script. Prescriptions for acute pain are not to exceed 30 tablets.
In Colorado, signs are going up in ER’s notifying patients that hospitals will not longer fill long-term prescriptions for opioid painkillers. Tighter controls such as mandating that providers look up patients in the state prescription drug database before doling out pain medications are under review. Bloomberg, not surprisingly, is getting in on the legislative bandwagon surrounding narcotics in New York. Under new city policies, hospital patients will no longer be prescribed more than three days worth of narcotic painkillers and prescriptions for long-acting drugs such as OxyContin and Fentanyl are prohibited. Lost, stollen or destroyed prescriptions are not to be refilled.
I’m conflicted over this new painkiller legislative fad. It would certainly be nice to have the law to blame in my battles with patients over their discharge medications. “Sorry sir, the law does not allow me to write a prescription for the medication you are requesting- maybe you should take up your penchant for Percocet with the governor”. In dealing with malingerers it would make my life easier.
Unfortunately, these laws will potentially work against many patients and medical providers. Some patients do necessitate more than three days worth of pain medication. The most obvious example that comes to mind is patients with fractures. They may not be able to follow-up with an orthopedist for more than three days, especially if they are uninsured. Many patients do not have the means to revisit a provider for pain medication refills every three days until their condition has resolved.
Laws restricting painkiller prescriptions can also negatively impact physicians, physician assistants and nurse practitioners. In general, I am against lawmakers further dictating what we are able to prescribe as medical providers. Legislation makes our practice much more cumbersome. It seems that with the passing of each new Medicare guideline and state law the amount of paperwork involved in medical practice becomes increasingly suffocating. Dr. Alex Rosenau, president of the American College of Emergency Physicians states “Here is my problem with legislative medicine, it prevents me from being a professional and using my judgement”.
What do you think about state regulations regarding prescription painkillers? Are you for or against state control of prescription pain medications?