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The back story isn’t usually a back alley

Today’s blog is a guest apperance by Molly Stevens who writes Shallow Reflections for BDN.. She shares her experience working in health care:

Consider the following two scenarios.

– Patient #1 had a life-sustaining blood transfusion before 1985 and contracted HIV.

– Patient #2 contracted HIV by sharing a dirty needle with an infected heroin addict.

Check your gut and pay attention to how you responded to these two unfortunate individuals. If you are honest with yourself you probably felt more sympathy for patient #1 who innocently accepted a medical treatment and later discovered it resulted in a life changing illness.

You may have felt compassion for patient #2 but also thought she was responsible for her illness through high-risk behavior. Some would have little compassion for #2 and would resent society’s responsibility for shouldering her medical expenses, citing this as unfair since she brought on her own problem. The harshest among us would say we should abandon her and hope she dies of an overdose.

But what if you learned that both patients were ‘victims’ of well-meaning medical treatments?

What if patient #2 had been given an innocuous prescription for Vicoden after a minor surgical procedure? She found they relaxed her and she took all 30 tablets even though no longer in pain. This prompted her to seek more prescriptions for pain relief. What if she couldn’t feel normal without taking a narcotic every day, and she needed more and more to go achieve the same effect? Eventually, the effort to obtain legal prescriptions would become too difficult and expensive, and she would turn to the cheapest, most accessible fix available.

Today that happens to be heroin.

Several years ago I had a minor surgical procedure on my lower lip resulting in eight stitches and scored a prescription for 30 Vicodin. I took one and realized it was like killing a fly with an elephant gun and stored the other 29 in my medicine cabinet, taking a few doses of extra strength Tylenol for successful pain relief.

There but for the grace of God go I.

According to studies nearly 80% of opioid addicts reported using prescription opioids prior to heroin. Some became addicted just like patient #2, by having legitimate medical conditions treated with narcotic pain medications, while others obtained the prescribed drugs from family and friends. By leaving 29 Vicodin tablets in my medicine cabinet I could have unwittingly contributed to this statistic.

I’ve been in healthcare long enough to witness the pain management pendulum swing from one extreme to the other and remember the days when pain meds were distributed sparingly. I recall requesting additional pain meds for a postoperative patient with this response from the surgeon, “Manage with the current orders. If he can’t handle it, that’s tough.”

I remember when joint commission cited hospitals for deficient pain management and pain assessment became the ‘fifth vital sign.’ I remember when oxycontin was released and aggressively marketed. I was the manager of a hospital unit at the time and continually ejected the oxycontin pharmacy rep who bypassed proper channels and arrived unannounced, armed with donuts and propaganda for the staff,

So well meaning practitioners heeded the call and began to be more liberal with narcotic pain relievers, meeting standards for joint commission and feeling good about a patient’s subjective lower pain score.

What we know now is that opioid abuse has escalated along with the number of prescriptions for opioids and the United States is the biggest consumer globally, accounting for almost 100% of the world total for hydrocodone (e.g. Vicodin) and 81% for oxycodone (e.g. Percocet)

Narcotics have their place in treating acute pain and there are times when opioids can be used effectively to treat chronic pain but they should be used when other methods have failed and must be carefully monitored to prevent addiction, respiratory depression, diversion, and dependence. These are not easy tasks when prescribers are already pushed to their limits and not experts in pain management or addiction medicine.

Strategies available to treat chronic pain conditions including exercise, physical therapy, and reframing one’s focus with cognitive behavioral therapy. I would like to see more support for nontraditional treatments like acupuncture, chiropractic, Reiki, therapeutic touch, and therapeutic massage to enhance pain management programs.

We all know that healthcare costs in America are astronomical. I don’t think I need to do a public health study to conclude that drug-related problems impact these costs.

But do you think there will be a multistory substance abuse treatment center constructed that looks like the Ritz when you enter the lobby? With nurse navigators and 24 hour on call providers eager to stave off relapses and treat the condition with the latest effective treatments researched with huge NIH grants?

I can dream, can’t I?

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