Wednesday, January 29, 2014

The slippery slope of prescription drug abuse

This physician's experience highlights the challenges we are facing as a state to address the prescription drug abuse problem in Colorado.

From:  The Denver Post

"Do you think that God wants me to hurt like this?" my patient pleads with salty tears trickling from puffy, red eyes. This cute, slightly overweight 40-year-old has just asked — no, begged — me for narcotic pain medication, Oxycodone.
Clean and sharply dressed, she had perfect make-up until it was marred by the tears. I had no answer to her question. Worse than that, I had no skills to say "no" to her drug habit. I knew well that one-quarter of her dosage was enough to kill me. Her daily prescription was enough to stop the breathing of a family of four. There were enough pills for her teenager to steal from the medicine cabinet to try out the "magic pills" that dominate a mother's life.
Yes, I checked the Colorado Prescription Drug Database. Yes, I saw the medication profile of a badly addicted woman, created by well-meaning physicians, including me, all because we were never taught how to say "no."

This woman is no derelict from the street. She is the mother of three, the oldest just into high schooI. Her husband works two jobs and takes the kids on weekends, often because their mom is too stoned to help with them. Years ago, I had looked into her eyes when they were clear, sharp and focused on squeezing a tiny baby through an impossibly small birth canal.
She did it well, all without pain-killing drugs. But over the years, a back pain here, an ankle sprain there, and a kidney stone one Fourth of July, allowed her to be gradually accustomed to the buzz of Oxycodone. At first, the withdrawal from only three or four pills a day was annoying, but mild. Xanax eased the pain of that withdrawal. Then she would stock up on prescription painkiler, just to avoid the hassle of running out on a weekend when no doctor was available.
Later, she would stock up on Xanax, for the same reason. Soon, there was enough on hand that taking an extra one here or there was easy. She didn't even notice the one or two pills stolen from the medicine cabinet by a curious teenager.
"I really need my pain medication. Please, help me."
Caring physicians, including me, have followed the principle we were taught: "Pain is an essential vital sign." "You must treat the patient's pain or you are not doing your job."
So we learned to listen to the patient's words and not attend to her overall health.
This patient may have pain in her body, but her addiction is a far worse illness. Her children are likely to become addicted to prescription drugs. She is likely to separate or divorce. She is likely to overdose on accident or on purpose.
"I don't know what God wants for you," I'd tell her. "I do know that you need help."
"Yes, doctor, I need help with this pain."
"You are going to hurt yourself with these drugs."
"Please, doctor, you are hurting me now!"
And we go around and around in a vortex, getting nowhere.
To make matters worse, there are very few substance abuse treatment centers. The few that exist are costly and poorly covered by health insurance.
The real solution was when she first reported back pain, the first chance to say "no." The real solution was back in medical training, when I needed to learn that a quick prescription today may be slow death to that patient tomorrow. We must teach young physicians how to say "no," what words to use, and what to do with the sad feelings that radiate from prescription drug addicts. We must teach patients the facts.
But none of this will help this patient this day. Any decision that I make would be wrong for her or for me. Any prescription that I write would leave someone feeling very bad.
And I will never have an answer to her question: "Does God want me to hurt like this?"
Warren Johnson ( is a family physician advocate for health equity in rural and urban Colorado.