Why I Don't Prescribe Pain Medicines

It may seem strange that a gastroenterologist like me does not prescribe pain medicines.  Let me rephrase that.  I don’t prescribe opioids or narcotics.   I write prescriptions for so few controlled substances that I do not even know my own DEA number.  You might think that a gastroenterologist who cares for thousands of patients with abdominal pains would have a heavy foot on the opioid accelerator.  But, I don’t.  Here’s why.

I truly do not know my DEA number.

I believe that one person on the health care team should manage the pain control.  In my view, this should be the attending hospital physician or the primary care physician in the out-patient setting.  There should not be several consultants who are prescribing pain medicines or changing doses of medicine prescribed by another physician.   With one physician in charge, the patient’s pain is more likely to be managed skillfully while the risk of fostering drug dependency and addiction is lessened.  We all know addicted patients who obtain medicines from various physicians and emergency rooms.  It’s cleaner when a patient on pain medicines knows that a single physician is in charge of managing this issue. 

While my argument of single physician authority can be applied to other medical conditions, this is even more important with narcotic agents.  For example, if a patient has an internist a cardiologist and a kidney specialist, only one of them should be managing the patient’s high blood pressure, at least in my view.   Since narcotics and related medications have addictive potential, it is even more important to have a limited prescribing source for patients. 

When I am seeing patients with abdominal pain, particularly in the hospital, I’m often asked for narcotics or to increase the dose or frequency of pain medicines that were already prescribed.  I counsel these patient that the attending physician is in charge of this and that the patient should discuss the request with this doctor. 

Other gastroenterologists and medical consultants may approach this issue differently.  I’d love to hear from them or from patients who have faced this issue. 

We can all agree that pain is the enemy.  But, the medical profession in its zeal to eliminate it, has contributed to the ravages and suffering of drug addiction.  In my state of Ohio, we lose thousands of our people every year to drug overdoses.  For many of them, their tortured path toward agony started with a medical prescription prescribed by a doctor like me.

Yikes! When Your Doctor's Computer Crashes!

Earlier this week, as I write this, our office lost a skirmish against technology.  It was my procedure day, where lucky patients file in awaiting the pleasures of scope examinations of their alimentary canals.  A few will swallow the scope (under anesthesia), but most will have back end work done.  We are a small private practice equipped with an outstanding staff.  We do our best every day to provide them with the close personal attention they deserve.

The first patient of the day is on the table surrounded by the medical team.  The nurse anesthetist and I have already briefed the patient on what is about to transpire.  Propofol, the finest drug in the universe, is introduced into her circulatory system, and her mind drifts into another galaxy.  I pick up the colonoscope, which is locked & loaded for action, and the screen goes dark.  Our nurse goes through a few steps of messing around with plugs and doing a quick reboot, but we are still in the dark.  I glance at the back of the scope cart and have an eye-popping moment when I see dozens of wires and connectors coursing off the cart in a collage of chaos. 

Ready, Willing, but not Able!

After 5 minutes, when it is clear that the Almighty has not declared, Let There Be Light, we transport the patient into the recovery area where she is awakened.  Patients in the recovery area never remember their procedure.  This time, there was no procedure to remember.

There was tension in our office as we contemplated our options for colonoscopy patients who took the day off, arranged for a driver and swallowed the required liquid dynamite to cleanse their bodies and souls.  We called the hospital who could not accommodate on short notice request for multiple procedures.  I was not willing to cancel anyone and told my staff that I would stay until midnight to get the work done.

Our IT professional was in our office in 30 minutes.  I think he was the youngest person in the building.  When your IT guy is sweating and stumped, you know you’re in trouble.

So, here we were with an able gastroenterologist, a crack staff, patients ready for probing, but we were paralyzed because a computer monitor was in a coma.  It’s a reminder that we have all had of how totally dependent we are on our technology.  Even at home when the modem goes out, we feel that our oxygen supply has been compromised. 

Here’s the denouement of the drama.  About 2 hours after the first case was to have started, we concocted a ‘work around’, which allowed our cases to proceed.  So, we won this skirmish against Technology.  But, I fear they are regrouping, lying in wait for their next strike.

Obamacare - Repealed and Replaced!

The House of Representatives enjoyed success weeks ago, depending on how one defines success.  Unquestionably, the passage of TrumpCare was a great political success that was not easily achieved.  I can’t fathom the intensity of threats and pressure that was utilized to convert a few ‘no votes’ into TrumpCare supporters.  The president and his team desperately needed a win after so many setbacks domestically and internationally.  And, this is a clear win, at least in the short term.  We will see if this vote becomes one that GOP House members can run on or will try to run from in 2018. 

Indeed, the GOP high-fiving and Rose Garden ceremony seemed premature considering that they have ascended only about 20% of their upward trek on an icy mountain as they hope to slog to the summit.  They may never get there.  The Senate, who have been quietly working on their own reform bill, are unlikely to endorse the House bill which contains antagonistic policies toward Medicaid expansion and pre-existing condition coverage.

The White House Rose Garden

Like Obamacare, this bill was passed without a single supporting vote from the opposition party.  Like Obamacare, this means that the effort is unlikely to attract the nation’s support, which is so critical for an issue that affects every American.  Imagine if Congress passed a declaration of war with votes from only one political party.  Would this be good for the country?   Could such a war be maintained when half the country opposed it initially?

The GOP’s mission was to achieve a win at any cost.  The Democrat’s response is to hope the reform effort soars over a cliff so they can benefit politically.  Does any reasonable person challenge me on these assertions?   

Leaving your own partisanship aside, do you feel that our legislators from either party care about our medical health or their political health?   Which institution – the Congress or the Health Care System – needs reform more?   Guess which one I’d like to repeal and replace?

Are You A Victim of Abuse or Neglect?

Words matter.  Patients can get spooked by the words we use.  All of us have heard vignettes of how some inadvertent harsh words from a physician have caused injury.  I know there were times that I wish I could rewind and erase some errant words. 

Sometimes, an innocent remark from the doctor doesn’t land innocently.   When I ask as a matter of routine, ‘is there a family history of colon cancer’, as I do with every patient, this may provoke anxiety in a patient who is seeing me for a bowel disturbance.

Words Matter

We ask every patient who arrives at our ambulatory surgery center if they have a living will.  This often causes the patient to utter a nervous joke.  We then go on to ask if the patient has ever been ‘a victim of abuse or neglect’.   We are required to ask this..  It would seem rather unlikely that a patient who has just purged themselves for the pleasure of a colonoscopy, would confess to a nurse that (s)he is meeting for the first time that (s)he has been victimized.  Keep in mind that this a question follows a barrage of very routine medical inquiries.

• Did you complete the laxative prep?
• When did you last eat or drink?
• Did you take any medications this morning?
• Have you ever been a victim of abuse or neglect?
• Who will be driving you home after the procedure?

Let me state unequivocally, that I am dead against all forms of abuse and neglect, both foreign and domestic.  I acknowledge that this is a serious problem that is clearly under-reported, particularly among the elderly.  I am skeptical, however, that querying our patients who are poised for an endoscopic adventure about a personal abuse history is likely to be enlightening.  A better case could be made for having these conversations in our office practices after we have developed rapport.

Who makes up these silly rules?   This is but one example of the documentation abuse that has been foisted upon the medical profession by the government and others.  I wish we could simply neglect to comply, but this boldness would only generate more government abuse on us.  

Memorial Day 2017

Freedom is not Free.

Expressing profound gratitude to all those who served our nation and serve today, and to their families who share their sacrifice.

Why My Patient Will Quit the Military

I had an interesting conversation with a patient in the office some time ago.  He was sent to me to evaluate abnormal liver blood tests, a common issue for gastroenterologists to unravel.  I did not think that these laboratory abnormalities portended an unfavorable medical outcome.  Beyond the medical issue he confided to me a harrowing personal tribulation.  Often, I find that a person’s personal story is more interesting and significant than the medical issue that led him to see me.

I am taking care to de-identify him here, and I did secure his permission to chronicle this vignette.  He is active duty military and is suffering from attention deficit disorder (ADD).  He likes his job.  He was treated with several medications, which were either not effective or well tolerated.  Finally, he was prescribed Vyvanse, which was a wonder drug for him.  The ADD symptoms melted away.  This is when military madness kicked in.  He met with military medical officials who concurred that this medicine was appropriate for him.  This decision, however, was overruled by a superior, since Vyvanse, is a controlled drug, which was prohibited.  My patient was told that he could choose between taking this drug or keeping his job.  In other words, if he opted for the one drug that worked for him, that he would have to quit. Who wins here?

Scales Tipped Against Him

While I do not know all of the relevant facts , this seemed absurd to me.  My guess is that the decision came right out of a Policy & Procedure Manual, which so often contains one-size-fits-all directives that override any measure of common sense.  It is this mentality that expels a first grader who kisses a classmate because the school has a rigid zero-tolerance policy against sexual harassment. 

When the patient was in my office, he had been off Vyvanse as required by his military superiors.  He was not feeling mentally well.  Not only was he off of his medication, but he was facing a profound professional decision that would change his life. 

And here’s the most ludicrous aspect of the situation.  The patient told me that other branches of the military had no issue with their servicemen taking VyVanse.  These branches apparently use  different Policy & Procedure Manuals. 

If this vignette is representative of the how decisions are made in his military branch, then they have a deeper issue to address.  Is there a medication that can combat rigid and robotic thinking?  If so, let’s hope it’s not a controlled substance.  

Patients Who Drink Too Much

When I am facing an alcoholic in the office, I do not advise him to stop drinking.  Other physicians may advocate a different approach.  We live in a free society and individuals are free to make their own choices.  I have decided, for example, not to own a firearm, ride a motorcycle or bungee jump as these activities are not only beyond my risk tolerance threshold, but are also activities that I have decided would not enrich my life.  Many smokers, though addicted, enjoy the experience and are aware of the risks of this activity. 

Preparing One for the Road

My responsibility as a physician is to inform and counsel, not to lecture or preach.  I tell alcoholics with clear candor the medical risks they face if they decide to maintain this lifestyle.  I advise them that if they wish to aspire to sobriety, that I will refer them to appropriate professionals for treatment.  I further inform them that in my decades of experience, very few alcohol addicts can quit on their own, despite their vigorous declarations that they can do so.  Finally, I tell them that if they decide to venture on the difficult journey away from wine and spirits, that I will be there at every step to assist and encourage them.  However, there is no hectoring or finger-wagging from me.  No threats or intimidation – which never work anyway - just cold facts and honest predictions.  The patient is then free to make his decision, as he is with any medical proposal.

Patients aren't obligated to accept my advice.  Indeed, the bedrock concept of informed consent places the authority of the decision where it properly resides, with the patient.  

Alcoholsim is an insidious disease whose tentacles slowly suffocate the addict and causes many friendly fire casualties.  Yes, I am aware that there may be a genetic predisposition to the illness, but at some point the decision to drink was still a choice.  Ultimately, only the afflicted one can cast off the chains. 

What do you think?  Am I derelict by not delivering an energetic exhortation, “You’ve got to stop your drinking!”  Is it my job to tell patients what to do, or to give them a fair presentation of their options so that they can choose for themselves?