Addiction

I was not on call this weekend, but here’s something that’s been bugging me during my time off: Addiction.

Before discussing the patient that has inspired my weekend worries, let’s talk background.

I seem to have encountered two opposing philosophies towards patients who have a drug addiction(s). Negative bias – A good friend of mine is a pharmacist and a few years ago she was giggling about her colleague’s clever way to circumvent this state’s needle exchange laws. In the particular state where I reside, it is legal for anyone to walk in to a pharmacy and purchase 10 sterile needles (I’ve never done this, but I think that the syringes are included with the needles). Of course we know the intentions behind this law were not try to get as many upstanding citizens of our community addicted to illicit intravenous drugs. I presume the intent was to decrease the spread of disease and perhaps even decrease the extrinsic costs (or is it intrinsic?) of treating such an addict using the taxpayers’ monies. My pharmacology professor was quite intrigued by Europe’s approach to heroin addiction, in that rather than putting the poor soul through the horrible detox process and then worrying about relapse… the enlightened Europeans know that the main problem with heroin addiction is impurities: Hepatitis C, HIV, tricuspid valve pathology, bacterial infection, etc. In theory, if someone had clean stuff they could live their lives disease-free, shoot-up in the morning (and at lunch) and keep their job. Supposedly this is the current approach in Europe. I have no references, but the idea is provocative. Though I doubt anything like that would ever fly in the US. The closest thing are these OTC needle laws.

Where was I going with that ramble? Oh yes, the clever pharmacist. So in-between my friend’s giggles, she managed to tell me that her co-worker will give the subcutaneous needles when a “shady” customer requests needles. Subcutaneous needles are maybe a cm long, so there’s little chance of acquiring a vein with such a tiny needle. “But is that legal?” I asked.

“Hee hee, they didn’t ask, and it’s not like she is going to help them,” she laughed.

Yes, that is a clever way to discriminate against this lowly portion of the population, but she’s also undermining the good intentions of the law. Hence, the above problems will continue and we’re that much farther from adopting the more accepting (and effective) attitudes of Europe. Hrm. Is this the part of the conversation where I am socially pressured to laugh in ignorant peer-pressure, or do I speak my mind?

Anyway, that’s the first philosophy I’ve encountered.

The second one I had not experienced until a few months ago at the beginning of my Family Medicine rotation. I walk in the room, introduce myself to an adorable elderly couple, and proceed to address their concerns. Nothing terribly exciting. They probably had the typical three problems: hypertension, hypercholesterolemia, and diabetes. At the end, before going and getting the Attending to review my assessment and plan for the future of these two, I like to check their prescriptions. Here’s a tip, if you get your prescriptions refilled when you’re seeing the doctor about something else, you won’t have to call them later (when your bottles are empty and your vision is blurring) and wait 72hrs to get a call back. I see that both have a prescription for benzodiazepines. Valium is amongst this classification of drug. Similar to barbituates, but those have gone out of style because ‘benzos’ are way safer. Don’t be fooled though they are safer, they are still quite addictive.

So I ask. “Whatcha need the diazepam for?” Perhaps they both cracked a hip lately and need some heavy-duty pain relief. Odd that they need it at the same time. All the textbooks say one should not be on them for longer than 4mos.

“Sleeping.” Really? I flipped through their charts (yes, there are offices that still don’t use electronic charts) and discover their prescriptions are at least 5yrs old. Hence, I’m quite sure they are nice and addicted to their “sleeping pills.” Mind you, the pharmaceutical industry actually does offer products specifically for sleeping. But ‘benzos’ are cheap. New fancy-pants sleeping aids still have patents pending (hence they are expensive because no generics are on the market yet). Diazepam (generic valium) is about $8/mo without insurance coverage. Lunesta, a sleep aid touted for being less addictive, is about $140/mo without insurance.

So Grandma and Grandpa are drug addicts. I run this by my attending who rolls her eyes. Silly little med student, you have much to learn. Grandma and Grandpa are 85+. They don’t drive so it’s not like they’ll endanger people whilst high behind the wheel of a Buick. They’re old, all they could ask for is a good night’s rest. By the time their addiction could kill them, they’ll be dead from something else.

Uhh… okay. Do I document this?

Actually, that would have been funny to write that their benzo addiction is acknowledged and condoned by their healthcare provider. I didn’t like that attending very much so it would have been nice to write something in her charts that would legally compromise her. I heard that once upon a time a med student wrote “Patient is getting full work-up for problem because patient has insurance.” Hee!

Wow, I am rambling! Can you tell I don’t want to study for my surgery exam?

Okay, so there’s the background.

Here’s what’s been keeping me up at night: A 67yo woman with breast cancer. She also has had numerous surgeries and Multiple Sclerosis. Needless to say she’s got chronic pain. But. She’s also high maintenance. I’ve seen patients who I know have chronic pain and they’ve found ways of dealing. This woman is on the other end of the spectrum. Oww this and OOOh that. By the way, don’t be high maintenance as a patient in the hospital or you’ll get poor service. If your nurse/doctor doesn’t like you, nothing will light a fire under their butts to get you an extra blanket, a timely cup of water, or hand you the remote that fell out of reach. Though I don’t blame this woman. I’ve never been in that kind of pain. I don’t know how I would handle it. Few of us have never had our pain tolerances really tested. So I don’t blame this woman for all her complaining and swearing (yes, don’t swear as a patient either, hospitals are professional environments). Though I do wonder if she’s hamming it up a bit.

For example:

The surgeon I am shadowing did this woman a favor the day after her radical mastectomy: he put in a port.

On Family Medicine, I had a patient take me aside and give me the “when you’re a doctor” soapbox speech. I like these. Please take advantage of the extra time you get with a medical student to tell them the non-medical aspects of your care. Anyway, this particular patient’s soapbox was about her ‘port.’ She had been diagnosed with breast cancer a year earlier and someone thought to give her a ‘port.’ Central Venous Port, for those of you who’d like to google it. Basically, it’s permanent access to a vein. This woman loves her port. No more needle sticks. No more collapsed veins. No more bruised arms/feet/hands. I’m sure her nurses loved it too because they don’t have to find a vein to collect her blood, just tap that port. So she wanted to tell me that my future breast cancer patients should get ports since they are in for a year of being stuck with needles otherwise.

Okay, back to the subject at hand.

No wait! I gotta tell you this funny story: So while I’m watching the placement of her port in the OR, the patient is covered in the ever-present blue cloth. The sterile area is cleaned with betadine and then everything else is covered with blue cloth so the area stays clean. Usually in the OR, one would assume the patient is asleep; however, that’s not always true. I’ve seen lots of cataract surgeries where the patient is kept awake so they can be given commands about moving their eye. I commend everyone out there who has ever had a cataract removed. I would definitely freak out if I were such a patient. Anyway, this woman was kept awake because there’s no need to put her under. The port is just a thin, long tube shoved up the main vein of the left (or right) arm. No cutting involved. She got some local anesthetic and then just laid under the blue blankets. The surgeon is talking through the procedure, describing what he is doing for my learning benefit and he says, “The textbooks say to put the tip of the catheter at the 5th-6th rib level. But I find with all these fat people, the ports pop out when they are that shallow, so I am putting this one in at the 7th-8th rib level.” No one said anything, but dude… the patient was awake. She heard him call her fat. She didn’t say anything either, but I would be mortified if I were her.

Yes, okay, that was morbidly funny. But I’m a med student. I like it when my superiors (who don’t let me forget it) shove both feet in their mouths.

After her port was finished the surgeon left, and the nurses proceeded to clean her off and get her ready to transport out of the OR. Yes, she’d just had her entire right boob removed, but even when they touched the right side of her chest (not the incision) she screamed out and shut her eyes and bobbed her head and panted as if they’d not only touched an owwie but also offended her entire existence. So yeah, I got the impression she was hamming up this pain.

The next day we go to check on her, and her nurse wants to have a conversation with the surgeon about her pain control. Mind you, this patient has emphatically told everyone (swearing included) that she has yet to have good pain control. She’s got her little self-controlled pump that allows her a shot of morphine (highest dose) every 5min if she desires, and she’s still complaining. Well, this nurse called the patient’s pain doctor and found out that the patient also has an internal pump for her back pain. Internal pump? I even googled it. I still have no idea what it is. But supposedly this magical pump, according to her pain doctor, administers a high dose of fentanyl (super-potent morphine) and bupivacaine (local anesthetic) internally. When the surgeon goes to speak to the patient, she complains to him about her pain and he says, “You’re on enough to kill an elephant.” Which is true. And he refused to give her more.

After leaving the room, the proactive nurse (c’mon, she even contacted the patient’s doctors who are not affiliated with that hospital. That’s some commendable leg-work.) was quite adamant, begging even, to have her pump taken away or at least have the time between fixes (I don’t think they call it that) increased. So that’s what the surgeon did, he lowered her dosage and increased the time between the patient’s ability to get another boost of pain meds.

But here’s what’s keeping me awake at night: the patient is in pain. Why did the nurse want her pain meds lowered? What would that accomplish? That wouldn’t detox the patient, nor would it control her pain. If we are going to assume this patient has an addiction going and we want her off all the drugs, why didn’t we follow the detox protocol? But assuming that only a minion of satan would want to detox a woman going through breast cancer therapy, why didn’t we acknowledge her addiction, but state that the current goal is to control her pain and detox will come later. So really, after spending a lot of time thinking about it this weekend, I think the point to lowering her meds was to punish her for being a whiner.

Think about it. Since when was an alcoholic no longer an alcoholic because he drank a lower proof of booze over a longer interval? Hrm. I feel like lowering her dosage and upping the interval time on her PCA accomplished nothing positive. I know very little about addiction medicine, but something in this whole thing lacks some logic. The woman is high maintenance and is nothing but trouble for all her nurses. Did they want her drugs lowered to punish her? Sometimes I get that impression. On Obstetrics nurses (and doctors) were rolling their eyes at patients in labor complaining of pain.

Or does the medical community really believe that with less meds she’ll be less of an addict. I didn’t know there was a spectrum like that. You’re either addicted or you are not. Isn’t this up there with the silly logic of “gateway drugs”?

So of course this woman is getting the worst service. And what was the next request from the nurse? (Don’t misinterpret this. Doctors are the ones to write orders and they don’t have to listen to a begging nurse suggesting the management of a patient should be changed.) The nurse wants her sent home. Yes, we all want patients to go home quickly. The longer a patient spends in the hospital the more likely they’ll get sick with something else (ie nosocomial infection).

So yeah, in summary the whiny patient’s management is this: don’t control her pain and give her the boot.

As a med student it is not my place to challenge. We are to be seen and not heard. If I really wanted to, I guess I could have played dumb and accidentally assumed that I am supposed to write orders for an addiction specialist to be brought in and hope my attending signs the orders without reading them (that rarely happens).

Bottom line is that I really just don’t feel right about how this patient (yeah okay, I’ll admit she’s not someone I would invite over for tea) was taken care of. But there’s nothing I can do about it.

The moral of the story is 1) I need to spend some free time researching the opinions of some specialists in addiction medicine. Perhaps it is effective to lower their meds and hope their bodies adjust; 2) If I am ever a patient, no matter how much pain I am in I need to be super gracious to the staff. Actually that’s a bit haunting since 10yrs ago I was hospitalized for asthma and I was quite ornery. (Dude, I couldn’t breath. ‘Please’ and ‘thank you’ weren’t on my list of priorities.) What if they lowered my breathing meds because of that and sent me home?

Tags: addiction, drugs, health