Wanting to alleviate pain but not enable addiction

In 1997, I was an Internal Medicine Resident with three small kids and a lot of bills. I got a moonlighting gig in the VA hospital in Sturges, South Dakota, to be the only doctor covering the med-surg ward, the ICU, the ER, the nursing home and the psych hospital, Friday till Monday, in the dazzling Black Hills. The driver at the airport picked up my bag and snickered, "New guy, huh? It’s bike week, you know?" I’d heard that there was a small "rally" but didn’t care because the pay was amazing and I needed the dough.

Bike week. Sturges, SD. A sleepy town of 30,000 swells to about 300,000 motorcyclists looking to party.

We passed bikes and people in all forms of dress and all level of intoxication. More women exposed their bosoms to our passing taxi than most mammography machines see in a year.

The moment I arrived, the ER was packed with a long line of rally-goers. I remember one typical visit. “What can I do for you?” I looked into the pinpoint pupils of a man who smelled of smoke, weed and Jack Daniels.

“I need dilaudid (a potent narcotic). I got pain.”


“All over.”

Right after he said that, he passed out, drunk and stoned and clearly in no pain.

Luckily, the ER nurse was superb. And tough. She suggested we announce that we would dispense no narcotics from the ER. I wasn’t comfortable with this, but I agreed. Like magic, the huge line of rallygoers evaporated into the night. I thought it was bad medicine, what I did with that blanket decree, by not giving the benefit of the doubt. (I did give a shot of demerol to one poor guy in agony with a kidney stone, watching his furrows of agony melt into opioid peace.)

Oh, how the pendulum swings. Prescription opioid overdose deaths quadrupled between 2000 and 2014. According to the New England Journal of Medicine, prescription opioid abuse plateaued around 2013. Unfortunately, street drugs have replaced prescriptions. ERs and ICUs continue to fill up with people so desperate to get high and to prevent their withdrawal sickness that they melt heroin in a spoon over a flame, suck it into a syringe and shoot it into their vein. It suppresses the body’s normal drive to breathe, and they asphyxiate. Every ER and ICU doctor and nurse I know has had to comfort the heart-riven family of an overdose victim many times over these last few years.

And so we now have burdensome regulations. To write for a narcotic, I have to register on a database, look up the patient on that database, write the electronic prescription, then await a text message confirmation code. Doctors are paranoid that the DEA or state regulators will show up at their door, and doctors aren’t prescribing narcotics. Patients are getting them on the street.

When I was an idealistic intern in the Emergency Room, I struggled with wanting to alleviate pain on the one hand and not wanting to enable addiction on the other. I was over-trusting at times. Other times, I was overly suspicious. I still don’t know if I was ever right.

A patient recently told me that his arthritis is so bad he buys Vicodin on the street in New London for a few bucks a pill. “I take it for the pain, not to get high.” I believe him. I think.



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