Uncomfortable Conversations

In 2014 Ohio won the shameful honor as “ground zero” in the Opioid Epidemic.  In that year 2,106 deaths occurred in Ohio due to opioid overdose (Cleveland.com November 30, 2016), more than any other state in the US.  California, a state with more than 3x  the population of Ohio, came in second.

I often ask young doctors, “What is your most uncomfortable conversation with your patients?” The most common answer I receive is not relaying prognosis or abnormal test results.  Overwhelmingly, the most uncomfortable conversations with patients are with those who are seeking opiates. I often ponder regarding individual solutions. But before solutions, we must identify sources.  Without avoiding advice on individual physician responses to patients demanding opiates let me first consider how we, institutionally and socially, find ourselves in these uncomfortable conversations.

As a start, the fact that there is an opiate overdose/abuse epidemic still seems to be a dead elephant in the living room for most emergency department personnel and what they do to patients in many ways sets the stage or scenario in which we later find the patient.  When I speak to ED physicians about the issue they appear to be aware of it but I cannot see that it changes their practices.  Thus the number of patients administered hydromorphone in the ED, usually given IV (which produces a euphoria akin to heroin), for questionable complaints of pain does not appear to be diminishing.  The patients then arrive on the floor primed with the expectation that this euphoric state will be maintained by the staff on the floor.  Most ED practitioners appear to have forgotten that all the drugs that we give for pain can be given subcutaneously and that there are modalities to address pain other than opiates.  Many ED physicians are afraid that their masters at the corporate level will penalize them for any patient complaints should they refuse the patients who “know” they must have opiates like Dilaudid (often with a little Phenergan on the side).  This scenario, in which a person with chronic pain or pain far out of proportion to clinical, radiographic or laboratory findings is treated with potent intravenous narcosis, is the one which most frustrates me.  To me it is one of the ways we initiate or enable addiction.

We could perhaps make history by being the first hospitalists to campaign to convene a mandatory meeting, followed by periodic mandatory meetings, of all hospitalists, all ED practitioners, pharmacy staff, nursing leaders and administrators to review narcotic usage in the hospital, both on the floors and in the ED, with review of any events such as respiratory depression or delirium induced by opiates.  The expressed purpose of such meetings could be “Intervention into the Opiate Crisis; “(Hospital’s) Role in Preventing and Addressing Opiate Abuse.”  The burning issue behind this demand would be the fact that thus far in 2017 a person in Cuyahoga County dies every other day from an opiate overdose.

As you may have discovered already, medical practitioners across the country are involved in similar institutional efforts.  If you google “reducing narcotic use in the emergency department” you will find a bounty of guidelines and articles describing successful efforts at all sorts of levels to help practitioners kick the habit of opiate prescription (pun intended.)  I like “An ER Kicks the Habit of Opioids for Pain,” found in the New York Times, 10 June 2016, which describes how a New Jersey Hospital Emergency Department cut their opiate use by 38%.  Harm reduction strategies are easy to find, constructed by institutions or various medical societies.

Harm reduction on the street is perhaps a way of framing your discussion of opiate intake with a person who clearly is seeking opiates that are inappropriate in their treatment.  At times, because the opiate epidemic is so potentially fatal, I go straight to questioning patients about what is the greatest threat to their lives, the intravenous use of street drugs, and simply ask them if they do that.  If the answer is affirmative, I then try to give them the lecture about how to reduce risk of death from overdose and complications of infection.  At SHM and other websites you can find detailed discussions about how iv drug abusers “cook” and administer their drugs and how to advise them to do so in the least harmful way, including procurement of clean needles and Narcan.  Most physicians do not know how iv drug abusers go about preparing their drugs for iv injection and an understanding of this is informative in comprehending the infectious complications we encounter as well as in advising addicts on how to avoid death and infection.

The issue of how to deal with the patient seeking inappropriate narcotics rapidly balloons outward from our need to protect the individual patient to the necessity of addressing and influencing a national medical epidemic of preventable death.

Peter S. Kibbe, MD FHM