Wednesday, January 09, 2008

The Narcotic Merry-Go-Round

The number of patients that I see who are prescribed chronic narcotic medications is astronomically high. Of course, there are many people who have pain worthy of taking narcotics on a daily basis---for cancer-related pain, post-surgical pain, etc---yet so many people abdicate their pain management all too easily to the drugs that will cause them physical dependence, constipation, and somnolence with no end in sight. As a person with chronic pain with an unknown etiology, I fully understand that strong drive to eradicate pain from one's life. Pain overtakes one's psyche, pushes other concerns out of the way, and leaves one desperate for relief.

While it is well-documented that pain is woefully and poorly managed throughout the United States, leaving countless patients suffering unnecessarily, I still find myself having mixed feelings about the ease with which so many providers seem to write those scripts for Oxycontin, morphine, and Percocet. At our local ER, it seems like there's a gum-ball machine near the revolving door, and patients simply have to say they're in pain and a prescription is produced in a knee-jerk reaction of instant gratification.

One of the questions we ask ourselves and each other about these patients on chronic narcotics is how long they will be on these meds? For the patients with failed back surgeries and other serious conditions, we consider that they may very well be on narcotics for life, and that is often the lesser of many evils. For others whose pain has no visible or discernible cause, we often question the intelligence of long-term narcotic use, understanding that tolerance will increase with time, and dependence only continue to deepen, both physically and psychologically. Now, often that dependence (which is different than addiction, mind you) is wholly warranted and acceptable, yet I feel that there is sometimes a lack of judiciousness on the part of the prescribers as they acquiesce to the pressure to write those scripts for controlled substances.

I do not question that narcotics are often needed for patients whose pain is not touched by non-steroidal anti-inflammatories and other non-pharmacological interventions, but sometimes I feel that those prescriptions move just a little too freely, especially when one considers that diversion (the selling of such medications to others for profit) happens on downtown street corners on a daily basis. Word has it, I hear, that our clinic is considered a great place to score some narcotics to sell at the bus station. A nice reputation to have.

Perhaps I feel uncomfortable with the amount of narcotics that fly off the shelves these days because a significant portion of my job these last few years has been fielding calls from my patients who are on chronic narcotics as they seek a new refill of their meds. Since many of my patients are former substance abusers and our level of trust in them is relatively low, some of them need to come to the office every seven days for a one-week supply of morphine or Percocet. While having to come in to see me weekly is inconvenient for them, it is equally a hassle for me in terms of printing up scripts, hunting down docs for signatures, and having all of this ready in a timely manner for frequently impatient patients. As I ready to leave my job of seven years, I quietly revel in the notion that I will soon enough finally escape from this narcotic merry-go-round.

Percocet, anyone?
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