Addiction and Pain: Who Gets a Script?

As if we as ER docs didn’t have enough on our plates already with proliferating drug shortages, adapting to the Affordable Care Act, the capriciousness of a new and very temperamental EMR, and my teenage daughter’s mood swings (wait, how did that get in there?), we also find ourselves under the microscope for our treatment of pain. 

Last month, the New England Journal of Medicine published a commentary on an Institute of Medicine report, “Relieving Pain in America,” starting with the alarming notion that, while we are on the one hand spending $600 billion on pain annually, at the same time we are somehow managing to “overlook” the true goal of relieving pain. Reading through the comments by the study’s senior authors, it’s clear to me that, in this epic-scale disaster, the ER is not directly in the crosshairs.

As ER providers, we often help patients manage chronic pain while simultaneously facing the daily barrage of those addicted to pain medication. It’s rare to have trouble distinguishing between the two. We try our best to manage each appropriately, which in the case of a narcotic addict almost always means NOT acquiescing to their desire for medication.

The summary of IOM recommendations recognizes the seriousness of both the abuse and diversion problems, and correctly notes the “effectiveness of pain treatments depends greatly on the strength of the clinician-patient relationship.” When a patient comes to the ER seeking drugs because of addiction, we are not fooled for an instant. Asking us for drugs is a blatant attempt to bypass that strong relationship. The IOM acknowledges this by specifically stating: “pain treatment is never about the clinician’s intervention alone, but about the clinician and the patient (and family) working together.” By refusing to provide narcotics, we are not denying a needed treatment, we are refusing to be coerced into a false role.

It’s easy to lose sight of the difference between our role as acute care providers and all the other front-line clinicians who also deal with chronic pain and chronic abusers. And I’d completely agree that a primary care doc or oncologist who withholds pain medicine out of suspicion that they are being played or, alternatively, over-prescribes narcotics to addictive personalities – for whatever reason – is yet one of the many components of our health care system that needs to be addressed. Recognizing maladaptive behaviors and then trying to fix them is going to be a truly tough undertaking, but fortunately it’s not the issue at our door.

Drug seekers are an aggravation in the ER. We can easily refuse to have the “My pain is 10” statement dictate our actions, and we can say no to giving a Percocet prescription. This won’t fix the problem, of course. One by one, though, we can take away the ER as a source, and this will help.