DOCTORS CHALLENGED WITH BALANCING PAIN, ADDICTION

Hurricane Frances had an unforeseen effect on a patient I recently
saw. It forced him to flee Florida without bringing any of the
narcotics he chronically took for back pain. It was so ghastly a storm
that he drove all the way from Florida without so much as a driver's
license for identification. Even if I had given him a narcotic
prescription, he would have needed some form of picture identification
to purchase them. The fear inspired by a hurricane is a terrible
thing. But then, so is prescription drug abuse.

It's a battle every doctor fights. From day one in medical school, we
want to believe people. We want to help them, and part of helping is
accepting the truth of their complaints. When we are first lied to,
young and new to medicine, we are angry and disturbed. Later, when we
have been sufficiently jaded, it's just a fact of life. By now, almost
every day that I work, someone presents me with a half-truth or frank
lie in order to get narcotics.

The battle is harder now than before. Medical science recognizes the
unique character of pain in every individual, and the fact that some
pain syndromes are hard to quantify. Many can't be found on physical
exams, can't be measured by X-rays or lab tests.

Furthermore, many organizations now exist to advocate for chronic pain
sufferers, from professional organizations of pain management doctors
to grass-roots patient groups. Also, large groups like the Joint
Commission for Accreditation of Hospital Organizations (JCAHO) have
taken up the cause, and look carefully at every hospital's plan to
manage pain, trying to make sure that it's liberal enough, watching to
see if we use a pain scale (is your pain a 1 or a 10?), and giving
facilities a professional frown if the pain care seems inadequate.

There's a reason. For a long time, many doctors were poorly educated
in the recognition and treatment of pain. Too many broken bones in
children were treated with only ibuprofen. Too many cancer victims
down the years were told to take acetaminophen. All because of an
inappropriate fear of causing addiction. Having experienced severe
pain in the form of a kidney stone, I can say that there are times
when only a narcotic will cut it.

Still, there are people who want prescription drugs just because they
like the way it feels to ride on a wave of euphoria. Some of them have
pain, but could use other modes to treat it; injections, biofeedback,
non-narcotic substances. Some once had severe pain and needed
prolonged treatment, but want the feeling of the drugs even though the
pain is now gone. And every year, our hospital sees a few who love it
so much they fall asleep and stop breathing forever.

A huge number of these people come to hospital emergency rooms for
their substance of choice. Some pain advocates (even physicians) say
to us, "You can't create an addict in the emergency room, so just give
them what they say they need." Most of us who write the prescriptions
feel that to do so, freely, contributes to the gradual dissolution of
lives, and also to the enormous pool of prescription drugs sold on the
street. It just feels wrong.

Furthermore, there are other organizations at the opposite pole from
JCAHO and others, notably the Drug Enforcement Agency and the South
Carolina Department of Health and Environmental Control, that take a
dim view of over-prescribing, and that will take away licenses (and
livelihoods) in response.

Personally, I'd almost prefer to legalize narcotics over the counter.
Not because there wouldn't be problems, but because it would take
doctors like me out of the middle. Advocates say that only a fixed
number will become addicted anyway. Fine, let them do it on their own,
without fabricating stories for me to tease apart.

But then there would be families with nowhere to turn for help.
Occasionally, in the midst of trying to decide if someone's pain is
real or ruse, I explain my concern that the patient is addicted.
Typically, they get angry and want to file a complaint.

But as I leave the room, their spouse, girlfriend, boyfriend or parent
slips out with me. "Thank you for doing that, I've been trying to get
them to stop for so long now! Maybe what you said will help," they
tell me. And then I know that for some, the drug battle is worth fighting.