Won't Get Fooled Again

Say what you will about The New York Times and newspapers in general getting smaller and less comprehensive and all that, they do provide a lot of food for thought. The latest? An article entitled "Fooling the Doctors, Some of the Time." It is a meditation on doctors and the dispensing of addictive medications, in this case benzodiazapines, but applicable, I think across the board to include interactions over pain medications. Here's a bit:

“It is better to suffer wrong than to do it,” Samuel Johnson wrote, “and happier to be sometimes cheated than not to trust.” Knowing that false positives are inevitable gives a statistical perspective to that wisdom — and frees the doctor from having to interrogate the patient like a criminal suspect. To put it another way, I’d rather be taken for a sucker once in a while than know that my suspicion had denied someone legitimate help. Furthermore, excessive suspicion compromises empathy and compassion. It is draining to approach patients as possible adversaries who must be bested.

In other words, according to the author of this piece, Dr.Michael W. Kahn, it is better to err on the side of prescribing for the patient then denying them. He ends the piece asking this question:

Since “first, do no harm” remains a guiding principle of care, let’s remember that the harm of missing a chance to help often greatly exceeds the harm of prescribing under a false pretext. Our system of justice is based on the idea that we should let the guilty go free rather than punish the innocent. Could our prescribing habits benefit from the same philosophy?

I had a multitude of reactions to this essay. My first reaction was a gut one, and was basically, "You've got to be kidding, these drug seekers will run your ass over at the first sign of weakness." Then I thought some more, considered patients I have known and assessments I have struggled to make, and realized that yes, the author does have a point. The patient and provider should not be involved in a battle over the drugs. In fact, patient and provider are supposed to work together, not at loggerheads. This conclusion says that giving the benefit of the doubt is the right thing to do. There are times this is not the right battle to fight. There are times you are not sure if you are dealing with real pain or really good fakery. The thing is, if someone has real pain, the compassionate thing is to give medication to help that pain. If we are not sure we are looking at real pain, we have to err on the side of giving medication that is likely to give relief, even if there is a chance the whole thing is an act to get narcotic medication.

Sometimes, though, I think drug seekers need to be confronted. I don't think they should always get what they want. A person will never hit the hard bottom if there's always someone sticking a cushion there. To go to an ER and hear that you will not be given the narcotic because you don't need it may be just what a person needs to hear. Pain medication is for medicating physical pain, not for getting away from a bad life or treating psychological pain. Some folks need to be told this at some point. That could be what it takes to get them going towards recovery, and living a drug free life.

Finally, there is that natural dislike for being played. No one likes to be a sucker, to be deceived, to give someone something that they don't need or deserve. No one likes being taken. That's when you can lapse into a "competitive cynicism" --and start thinking that no one is to be trusted in their complaint. You cannot give good compassionate care that way. The moment you start thinking that everyone is out to game the system is the moment to consider taking a break.

One last thing: It's amazing to consider how much of an ER's energy and time is consumed with people with chronic pain complaints and drug seeking behaviors. Just take a look at my ER oriented blogs in the blog roll. These types of patients are a pretty common blog topic for the ER doc and nurse bloggers. I don't know what the stats are, but I won't be surprised that chronic pain and prescription drug abusing patients are a good 25% of ER clientele. It's too bad we can't find a better way to work with patients on these problems then in the Emergency Department.

In the end, assessment needs to be diligently done. If it's time for a patient to hear the truth, then tell it. If you are not sure, then I agree with the author, give the addictive prescription medication. If you are an ER doctor, and too many chronic pain/drug seeking patients like you, you may be too easy. If you are an ER doctor, and those patients hate you, you may be becoming too cynical. It's a tough balance, that takes up a lot of a provider's psychic energy.