The over-prescription of opiates: food for thought.

Almost every day there is something in the paper or on the news about the rising heroin addiction and fingers being pointed at doctors and the prescription opiates that they prescribe. I am by no means backing the doctors who haphazardly prescribe opiates without ever seeing patients or knowing full well that their patients are addicts.

But David read one piece today about how Fentanyl is being mixed with heroin, which will likely result in Fentanyl prescriptions falling under greater scrutiny. Why is Fentanyl prescribed?  It's a long acting opiate, and it's strong...but it's typically reserved for the people with long standing intractable chronic pain.  In other words, it's usually for the very, very sick...like the dying cancer patients who have cancer in their bones and every subtle movement...turning over in bed, sitting in a chair, standing, not to mention riding over a bump in the car or sneezing...causes horrible pain. Those are the people who are going to have to wait longer in line at the pharmacy now to prove that they have a new hand signed prescription to treat the pain of their terminal diagnosis...when standing hurts. As if their situation doesn't suck enough as it is! Those people really, really need a pain killer like Fentanyl and it's unfair that it could be even harder for them to get the pain control that they need in the future. 

I don't claim to be any expert on the opiate crisis, but I think there is something else underlying the prescription of pain meds, which I haven't heard one media broadcaster talk about.  WHY are  opiates being doled out after relatively minor surgeries, or for pain that should probably be controlled with acetaminophen and ibuprofen?

When was the last time you went to the doctor?  Did you get a survey in the mail one week later??  How did your doctor perform?  Were you happy with the service?  Did they take care of your needs?  Was your doctor easy to communicate with?  Healthcare is now a customer service-based industry. I guess that there were some good things that came of this - some of those looney toon doctors who shouldn't be practicing medicine maybe no longer are (I don't know that for sure) or maybe doctors in general started to listen to their patients more about their needs (but I don't really know if that's true either).

What I do know is that almost all doctors have been pushed by hospital administrators to see more patients and do more surgeries/procedures in any given week.  Reimbursement is not the same, so for the hospitals to profit, or even in private practice, for a practice to survive, doctors have to see as many patients as possible. 

We have also learned of the risks of keeping someone in the hospital too long - increased risk of complications of immobility and risk of infection. So we push really hard for people to go home asap, usually before they feel ready. I can't tell you how many post-op patients we have had to spend half a day convincing that it's time to remove the Foley catheter (bladder catheter for urination when you can't move).  Often patients don't want it out because that means they have to get out of bed to go to urinate and they don't want to face the pain of starting to move again after a major abdominal surgery. But the risk of them not getting moving at that point and not taking out the catheter at that point is potentially way worse - blood clots in the legs that than dislodge and travel to the lung/heart, bladder infections that can lead to kidney infections or sepsis, bed sores from immobility that again lead to infection and sepsis. A lot of big procedures are followed by same-day discharge now in addition to the patients who have minor surgeries and have been going home on the same day. 

So imagine this now - you are a surgeon.  You have an operating room open to you on Friday and it is fully booked with patients coming in for minor procedures, things that people can have done and then go home after.  Everyone does well (yeah!) and they all go home before the night teams come on. You made sure all of your patients went home with adequate pain control. For one patient, you recommended tylenol and ibuprofen only. Being the "astute physician" that you are, you did NOT prescribe opiates because that patient had a history of alcohol dependence.  Patient goes home, can't sleep because pain is bad, calls the hospital in the middle of the night, the night team answers and isn't sure what to do, they page YOU at 2am, you explain why opiates were not prescribed but since the patient says the tylenol/ibuprofen aren't enough, the decision is made to write for Percocet or Oxycontin. The patient needs a paper signed prescription (can't be called in to the pharmacy), patient angrily comes to hospital to get signed prescription in the early am, and then ...gets a survey in the mail.  She writes:

"My doctor did a good surgery but he sucks because he thinks I'm an alcoholic and didn't give me good pain control.  I suffered all night because of him and he was not available when I needed him most."

On a scale of 1-10 how would you rate your doctor: 1

But wait!  He didn't kill you on the operating table!  In fact he did your surgery faster than expected, with better outcomes, and closed the tiniest incision so carefully so that the scar that will barely be noticeable one day. 

See the problem here?  These performance measure surveys are received by hospital administration who COULD try to improve hospital communication, but will more likely critically review how much the hospital needs that doctor - do they see enough people, make enough revenue for the hospital, should they take away some of doctors compensation or better yet, let him go all together.

Does anyone else see this as a potential problem with the system?  Could the over-prescription of opiates have SOMETHING to do with hospital administration pressures to provide good customer service rather than good medical care?  Prescribe or lose your job?  Just food for thought...