Notes from an emergency room doctor: Under a
counter at the nurse's station in our E.R., hidden
amongst a variety of log books and technical manuals
is our "frequent flyer" cardfile. This
is not our list of patients whose frequent trips
to the E.R. entitle them to a free visit but rather
a record of patients frequently seen and frequently
prescribed potent, narcotic pain medications.
Most often these are people with chronic headaches
or backaches. For the most part, they are people
who indeed suffer from frequent, often intractable
pain. But scattered among them - and knowing who
is who is often difficult - are the abusers, those
whose need for narcotic painkillers is not so
much due to pain but to dependence and addiction.
The reason most patients visit a doctor is not
so much for a "cure," but for relief
from pain. This "relief," that doctors
can so easily bestow simply by prescribing appropriate
analgesics, is perhaps the greatest service a
doctor can perform for his patient. But the message,
"Just Say No," and the national furor
over narcotic abuse, has carried over into the
prescribing habits of doctors. Most doctors today
are afraid to liberally prescribe the most effective
painkillers, which are narcotics, because of a
fear of creating dependence or addiction in their
patients or of falling prey to the machinations
of narcotic abusing patients.
Dependence, addiction and abuse are the issues
that frighten doctors more than their fear of
under treating a patient's complaint of pain.
This fear becomes indelible the first time a physician
learns of one of his patients arriving in an emergency
room in a coma or even dead after overdosing on
a prescription of painkillers he's written.
Dependence can occur if someone takes opiod
drugs for more than a few days. Dependence simply
means that you'll have physical withdrawal symptoms
if you stop taking the drug. However, physical
dependence in and of itself is not bad. Uncomfortable,
"yes," life threatening, "no."
Addiction is both the psychological and physical
dependence on the medication. Basically, a person
loses control over their drug use. They have an
overwhelming urge to take it, even though there
is no need for it, and even when they know taking
it could cause them harm.
Abuse occurs when a person becomes so dependent
on a drug that they will stop at nothing to get
it. They often lie or steal to get it. All reason,
all morality may be shunted aside to service their
addiction. Anytime a drug promotes aberrant behavior,
it is considered abuse.
When a patient is caught in a lie to doctors
or family, when a mood or behavior is strange,
that patient becomes suspect for addiction. It
is not an isolated case that a patient will fake
the symptoms of a kidney stone or heart attack
to obtain drugs. It is not unusual to get a call
from another emergency room warning of a patient
who has been hopping from E.R. to E.R. with a
good enough act to get narcotics from each one.
Certainly there are specialized non-narcotic
drugs that treat specific pains - like the anti-inflammatory
medicines used for arthritis or the vasoactive
drugs for migraines. But the narcotic pain medications
- morphine, codeine, and their derivatives - despite
their potential for abuse, are often the most
effective drugs in providing relief to patients
with severe or chronic pain. And it is that release
from pain that can significantly improve a patient's
quality of life.
It is a sad fact that the greatest gift a physician
can give his patient - relief from pain - is often
withheld because the behavior of a few has jaded
us to suspect all patients to be at risk for dependence,
addiction, and abuse.
And though a doctor's greatest wish is to "do
some good," that goal has to come second
to "first do no harm."