The use of opioids for chronic pain is a difficult subject to approach with patients. In the 1990’s, these medications were used excessively for pain control. However, at that time, we were not aware of the addictive nature of these medications. Currently, roughly 130 people die every day due to opioid overdose and more than 11.4 million people misuse prescription opioids1. In 2017, the US department of health and human services declared opioid misuse as a public health emergency.
In the hospital, it is very difficult to have a one-to-one conversation with patients on how and why to stop opioid use. Sometimes, even despite our efforts to reduce opioid usage, we may find that patients are receiving medications through “other ways.”
The following is a narrative medicine essay on the topic of approaching opioid usage in admitted patients:
I started my day off on such a high note. All of the vitals were stable and all of the labs looked pristine. The social worker may have found placement for a patient, Mr. L, that had been on the service for 3 months. This was going to be a productive day.
I picked up my white coat, my stethoscope, my list, and walked to the medicine nursing unit looking for Mr. L’s room. As I approached his door, I quickly spotted an alcohol dispenser and swiped my hand underneath it.
I quietly opened the door and walked into the private room. I saw Mr. L sitting on the side of his bed, watching the news. He had been readmitted to our service yesterday for shortness of breath, likely due to his heart failure. The oxygen was wrapped around his nose and he looked calm. As I walked towards him, his face turned towards me with a grimace.
Mr. L: “Why did you take away my Norco? I told you when I came in yesterday that I use them. This bed – it’s so uncomfortable and hurts my back.”
Me: “No ‘hello doc?’ No ‘how are you?’ At least let me have the first question,” I said as I sat down on the chair next to his bed. He chuckled for a second but went right back to his grimace.
Mr. L: “I’m sorry, doctor. I like you, but you young doctors don’t seem to understand. Everyone keeps on telling me my heart isn’t working right. I have so much trouble breathing and these fluid pills aren’t doing what they normally do. I’m dying, and yet, here you are, taking up an issue with my pain pills. You didn’t order them for me last time, and you’re doing it again.”
I thought back to my team’s daily rounds where Mr L’s opioid use was always mentioned in the problem list as “opioid misuse” and our plan was to repeatedly address our concerns with him.
Me: “Mr. L. Norco is the last thing you need right now with your breathing. It’s very addictive, and I don’t think ethically it would be right for me to start it.”
Mr. L: “This whole addiction business started with people partying back in the 70’s, shooting up heroin. You’re going to lump me into their group now? So, because of them I can’t be pain free while I sleep here?”
I take a pause.
Me: “I understand your frustration, but these medications are not meant to be used like this. There are patients with wide spread cancer who are using the doses you want. It’s just not reasonable.”
He looks down. I try to change the conversation. “So, how is your breathing? Getting better?”
I asked him all of my routine questions, completed a physical exam, and told him about how we needed to increase the dosage of the fluid pills we were using. He agreed with the treatment plan. I shook his hand and stood up to leave.
As I walked towards the door, I heard him say, “So, you’re not even going to discharge me with a refill?”
I turned back. “No, I’m sorry. You know, there are other medications set up that you can use if you would like to taper off of the Norco, but I can’t prescribe them. You have to see a pain management specialist.”
Mr. L: “Oh so another appointment for me to get to? You know what, that’s okay. I know people from all walks of life, if you catch my drift, doctor.” He looked back at the television.
There are many social factors that make opioid misuse a difficult issue to address in the hospital. As physicians, we must recognize that although we may not be prescribing these medications, patients may be receiving them through other avenues. The best method may be to do our best to set up a good physician-patient relationship and educate patients on the adverse effects of these medications.
- U.S Department of Health And Human Services,“What is the U.S. Opioid Epidemic?” https://www.hhs.gov/opioids/about-the-epidemic/index.html, January 22nd, 2019