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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."