A Tale of Two Patients

PATIENT #1: A 31 year old man admitted to the ICU status post respiratory arrest.

It’s 5:45 AM and I’m scanning the list of new admits to the ICU and I’m struck by this man’s age and presenting complaint. Walking into the patient’s room his 6’4″ frame leaves his feet hanging off the bed. His left arm is covered in a sleeve tattoo and in his curled up hand is a green rosary. Two hours later when we round on the patient as a team he is joined by his family. His father shares a similar build and tries desperately to hide his blood shot eyes and tear stained face.

For 3 days we tried to undo the damage the respiratory arrest had done to his body. Therapeutic hypothermia was initiated  to cool the body and protect from further damage. We adjusted his vent settings and pumped him full of fluid. When his heart went into pulseless V-tach we shocked it into a normal sinus rhythm. But physicians aren’t miracle workers and none of the interventions changed the fact that he was brain dead. After many long, tough talks with the family they were agreeable to donating his organs.

On a cold, snowy Tuesday night he was wheeled to the OR. A transplant team from Mass General had flown in for the organ procurement. Before the procedure began, a letter, a dad’s final words to his son, was read and a moment of silence was observed. His family sat in the waiting room, withdrawn, no more tears to cry.

PATIENT #2: A 37 year old man presented to the ED with nausea, vomiting and diarrhea.

I escort the patient to his room on a quiet Sunday morning. He’s talking to someone on the phone, and he is not concerned that there is a physician, a nurse, and myself waiting on him to finish his conversation as we stand at the foot of his bed. Finally after the third time he was asked to hang up the phone he turns his attention to us. He immediately begins writhing in pain, alternating holding his abdomen and then his head. He interrupts the interview to demand a warm blanket, and then a glass of water. The doctor and the nurse give up in exasperation, there are other patients waiting to be seen so they task me with finding out what ails this man. I begin running through a review of systems, a standardized check list to elicit a medical history from a patient.

Fever? chills? Yes to both

Headache? Yes

Trouble Breathing? Chest Pain? Belly Pain? Yes, Yes & Yes.

I step out of the room to go discuss this case with my attending physician. Although we both believe this man is malinger, which is when patients exaggerate or feign illness in order to gain something in return, it is our duty to ensure that there is nothing medically wrong with the patient. He spends the next couple hours terrorizing the department. He is walking into other patients rooms. He’s screaming at the top of his lungs followed by a series of expletives. He’s punching at the wall and knocking over furniture in the room. He floods a bathroom by shoving a pillowcase into the toilet. Security is called to his room twice. He ends up leaving the department AMA (against medical advice) only to return several hours later. Waiting to be triaged he gets in a fight in the waiting room and the city police are called. Ten hours after I evaluated him the first time he winds up back in the same patient room and the process is started all over again.

So what do these two men have in common?

Both of the men are heroin users.

Patient #1 was found down, a needle in his arm. EMS had given him 3 doses of Narcan in route to the hospital. His overdose caused him to suffer a respiratory arrest. He never regained consciousness.

Patient #2 had last injected heroin about 5 hours prior to his first admission. He was experiencing the classic withdrawal symptoms of nausea, abdominal cramps, muscle aches, agitation and restlessness.

In October of 2017, President Trump declared a state of emergency over the opioid crisis. This came 2 months after an Indiana doctor was slain in broad daylight after denying a patient’s opioid prescription request.  Dr. Todd Graham was an Orthopedic physician. He was seeing a new patient who complained of chronic pain. The patient and her husband insisted on an opioid prescription and in light of today’s opioid crisis and health official warnings Dr. Graham refused. The husband became irate and an argument ensued. The couple left, but the husband returned hours later and gunned Dr. Graham down in the parking lot of the hospital.

In my two years of rotations, I have encountered 3 patients that made me fearful to leave the office and all of them have been opioid seeking patients. One of these patients had come to our office with a fake name. Walking in with a cane he described a horrific car accident last week that has left him with debilitating pain. After being told he would not receive a prescription he was furious, throwing his cane at the medical assistant and stormed out of the office. We later discovered that in the past month he was able to obtain more than 40 different prescriptions for opioids at various hospitals and clinics throughout the surrounding states.

How did this happen?

It is estimated that opium was discovered in 3400 B.C. in Mesopotamia by the Sumerians who nicknamed the plant as the “Hul Gil” or “Joy Plant”. This plant became known for its ability to induce euphoria and was passed to the Assyrians who passed it on to the Egyptians. In approximately 460 B.C. the father of medicine, Hipoocrates, was the first to acknowledge the use of opium as a treatment for internal disease. In 330 B.C. Alexander the Great introduced opium to India and for the next 1,000 years there are references to the use of opium by Arabs, Greeks, and Romans.

The spread of Opium across Asia, Northern African and Europe continued exponentially until the Holy Inquisition began in the 1300’s when anything brought from the East was thought to be linked to the devil. For approximately 200 years there were no references to the use of Opium in European history. It wasn’t until the peak of the Reformation that opium was reintroduced into European medicine as a pain killer.

The use, and abuse, of opium derived medicine is nothing new. Yet, according to the CDC the sales of prescription opioids and death from prescription opioid overdoses have quadrupled in the United States since 1999. So why now? What changed?

In the mid-1990s the American Pain society pushed the idea of pain being the fifth vital sign because they believed pain was not being addressed by patients and was under-treated. This resulted in the pain scale being added to the standard assessment of a patient, as common place as measuring a blood pressure or taking a temperature.

Pain Scale

However, unlike blood pressure or temperature, a pain scale rating is subjective and has been skewed as a measure of patient satisfaction.

This was brought to my attention as  I flipped through the pages of a fashion magazine on my day off. Between the perfume advertisements and latest trends was a full-page of black and white pictures with a caption below it stating that each day 31 women die due to opioid addiction. Intrigued I began to read the accounts of these woman who are battling their addiction.  I actually felt my face-flush and my stomach turn in knots as I read one girl’s account about becoming addicted to narcotics after taking the prescribed opioids for a minor surgery. To quote the article, this patient “wishes her doctor had thought twice before prescribing Percocet”. This patient continues to say that “I just did as the doctor said. I never took into account that, Oh, maybe I’ll abuse these pills”.
Truthfully, reading accounts like that, it feels like a lose-lose situation to be a physician.
For every patient that believes their doctor forced them into an opioid addiction, there are 5 more patients pounding down clinic doors demanding their pain be addressed. If their pain is not addressed they shout from the rooftops about how their physician abandoned them and left them in pain. In the case of Dr. Graham, denying someone opioids for their pain cost him his life.  The root of this problem is far bigger than doctors overprescribing.

 

No doctor writes a prescription intending to get a patient hooked on medication. When used as directed opiate pain killers do play a role in pain management and can be prescribed and used responsibly.

No patient chooses to become a heroin addict.

So it’s time to stop the blame game.

Realistic Expectations. Surgeries hurt. Broken bones hurt. Traumas hurt. Expecting to go into a surgery and wake up pain free or fall from a roof and not feel anything is unrealistic and unobtainable. Americans account for 80% of opioids used worldwide yet we have similar rates of accidents and pain scale scoring as other nations. As a society we need to readjust our expectations of medicine and our perception of pain.

Pain Management Alternatives. Several of the surgeons I have begun working with will re-anesthetize the area that they incised at the conclusion of a procedure, and now there are long-acting anesthetics that are becoming more common place. Some physicians are prescribing pain patches over pain pills to break the cycle of pill popping and medication dosing every couple of hours. Aside from pharmacology there are other pain management techniques such as Osteopathic Manipulative Treatment which has great efficacy in treating muscular pain and improving mobility and the body’s ability to heal. Some less common approaches to pain management include acupuncture which has shown efficacy in treatment of chronic pain.

Let’s Promote Health. Healthy bodies heal faster, its a fact. Yet as a society we are failing in the health department.

In the United States their are 36.5 million adults who currently smoke cigarettes daily. According to a 2015 National Survey on Drug Use and Health 56% of people over the age of 18 report consuming alcohol in the past month and 15.1 million adults reporting they have alcohol use disorder.  Both tobacco and alcohol use slow down a body’s ability to heal. Slow healing wounds prolong pain and increase the risk for long term sequela. Maybe before we allow patients to get elective procedures we should require them to break their smoking habit and to cut back on their alcohol consumed.

There is also a link between obesity and chronic pain, yet 36.5% of US adults are obese. In addition to increasing rates of pain, being obese has an impact on how all drugs are metabolized in the body yet there is an alarmingly low amount of research on how the pharmacokinetics of opiate derivatives changes in those who are obese and how this should impact dosing instructions.

Lastly, there are 40 million adults in the United States who suffer from anxiety and 16.1 million adults who have been diagnosed with Major Depressive Disorder in any given year. Both pain and depression are influenced by serotonin and norepinephrine levels, and dysregulation of either can result in more severe and irretractable pain. Yet when a patient complains of acute pain, very rarely do doctors look at managing depressive symptoms and patients are rarely happy if they leave without a pain medication. Although there is hope on the horizon, some long term pain management clinics have started introducing therapy and yoga into their practice as supplements to pain medications.

Maybe if our nation started focusing on prevention and improving our society’s health then we could decrease the need for long term pharmocologic pain management.

Help those that need help. As mentioned earlier, Narcan is a opioid antagonist that when given temporarily reverses the effects of opioids. Narcan is available as both a nasal spray or intramuscular injection. Did you know that you, yes you, can go to a pharmacy and obtain narcan without a prescription (Unless you are a Nebraska or Michigan resident in which case you would need a physician’s prescription).

We are in the midst of an Opioid Epidemic. While you may not personally know of anyone using opioids I can guarantee that abuse is happening in your community. I was shocked when patients started being brought the the Emergency Room from the stores I shop at and the neighborhoods I live in. Opioid Abuse is not reserved for seedy parts of town and the shady people who mill around in alleyways and abandoned parking lots. Men, women, parents, graduate students, business owners are falling victim to addiction. While I don’t support the behavior and I don’t want to encourage someone’s continued addiction, narcan is the only thing that can temporarily revive someone who over doses from heroin or other opiates.

I carry narcan with me so that if I am ever faced with the situation, that I can do something to prevent another family from having to mourn the loss of their son gone too soon.

 


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