In my role as Director of Patient Experience I recently met with a pair of physicians at one of our hospitals. Before we began discussing how best to serve our patients, they forcefully and adamantly brought up an issue which causes them great frustration and consumes their daily rounds. The issue, written about extensively and often satirically concerning patient satisfaction, is the conflict between hospital physicians and patients who are chronic opiate users. They discussed how that plays out in the context of hospital administrators looking for high patient satisfaction scores and some nurses who advocate liberal dispensation of narcotics to patients with chronic conditions.
The background of this is a current epidemic of narcotic abuse, narcotic related death and narcotic mis-prescribing in the U.S. Deaths from prescription opiate medication have quadrupled in the U.S. over the last fifteen years (this figure does not include deaths due to cheaper opiate medications purchased on the street.)
The physicians who spoke to me felt that the problem starts in their community, where local physicians very liberally prescribe narcotics and benzodiazepines on a chronic basis to their patients. The physicians argued that these patients when admitted for various conditions not related to pain demand an upward dosing of their oral narcotics to intravenous narcotics in the hospital. The physicians noted that this intravenous narcosis began in the emergency department, sometimes with disastrous results of respiratory depression, and they implied that this was done because the emergency department staff was worried about their patient satisfaction scores. I express their opinions, I do not assert fact.
These physicians further felt that the nursing administration and medical leadership of their hospital frustrated them in their attempts to curtail chronic administration of opiates to patients in the hospital who did not have malignant pain, thus furthering a cycle of addiction within the community.
These physicians felt they had no allies within the hospital or the community that might enable them to become part of the process of addressing the narcotic abuse epidemic within that community.
Hospitals and health systems have successfully addressed this problem. It has been extensively documented, studied and chronicled. There are solutions. We now have the most current and very recent Centers for Disease Control guidelines that favor non-narcotic approaches to chronic pain other than malignant, usually oncological, pain.
My advice to anyone considering patient satisfaction scores is to state unequivocally that issues of patient safety and good medical practice always always trump any issue regarding patient satisfaction. This is a line in the sand. No physician should, under any circumstances, prescribe anything or communicate anything that is not in the best interests of the patient in order to elevate patient satisfaction scores.
In a perfect world of hospital medicine, and given the enormity of the public health problem that is narcotic dependence, each hospital would convene a working group of involved staff, from emergency staff, primary care systems, hospitalists, pharmacists, nursing staff and care coordinators to devise a means of addressing the issue of narcotic administration. They would cooperatively develop hospital guidelines for the use of narcotics for the patients in any part of the institution who are current chronic opiate users. Recognition that the use of narcotics for chronic non-malignant pain should be subject to CDC guidelines would have to be foundational in seeking clinical pathways forward in managing this problem.
In the short term, hospitalists’ groups can devise their own means of developing uniform approaches to the problems related to the treatment of hospitalized patients who, as outpatients, are chronically habituated to narcotics.
We must start with the understanding that chronic narcotic dependence is a disease. However it came about, it is an addiction that is not unlike other categories of addiction such as tobacco or alcohol dependence. Patients with these problems do not benefit from shaming, scorn or moral condescension. These problems know no class or gender boundaries. Consider that some of the stars in the constellations of people who revolutionized medical thinking were addicts: Sigmund Freud painfully freed himself from cocaine addiction. Halstead, who spent his life advancing surgical science, struggled with cocaine and morphine addiction.
We must recognize that as hospital-based physicians we have limited exposure to these patients and cannot within a short hospitalization period attempt to resolve their dependence. It is not reasonable in most cases that we can expect to detoxify these patients while they are in the hospital.
That being acknowledged, we can attempt to limit narcotic administration to them and not escalate their dosages. This will entail personal interactions with the patients in which we directly address the fact that they are habituated and that we feel that habituation is dangerous to their long-term health. The use of the “I” statements in these conversations is helpful: “I see that you have been using narcotics for a long time for your chronic problem and I am afraid that the long term effects of this are injuring your health. In addition to that I do not want to prescribe more narcotics to you because I am afraid it might harm or even be fatal to you. I have seen people die due to excess narcotic prescription…”
We should not forget that we can forge alliances with competent pain management physicians, primary care physicians and others in individually managing these patients.
Finally, we are under no obligation to supply outpatient prescriptions of narcotics to patients when they are discharged.