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I see a lot of this from the health care provider side of things. I'm a doctor in Kentucky and dealing with people who are addicted to opioids is probably the most challenging part of my day. Mostly because the addiction itself puts you and the patient in an almost oppositional relationship by default on the inpatient side of things. The heroin tends to cause health problems that tends to put you in the hospital that tends to put you into an environment with professionally placed IV access and a pharmacy stocked with dilaudid. I know they're going to withdrawal and that amounts to a temptation I will never understand, and I also know that unless they have something verifiably painful like pancreatitis or an ischemic digit giving them opioids is just feeding the addiction. It takes me a few minutes before walking into the room to get into the head space and remind myself they're here to get help, that they're people too, and that addiction is not something you can choose. It gets tough because there's not a lot of resources for recovery on the discharge end of the stay and even if you can get something set up, not much really works well to assist in recovery beyond social support networks.
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Apr 4, 2016 13:44
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| # ¿ May 6, 2024 15:26 |
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pangstrom posted:On some podcast Tom Arnold mentioned he got in a motorcycle accident and while he was lying on the highway with a broken back his first thought was "sweet, I'm going to get morphine." And IIRC correctly he was in recovery for cocaine at the time and had just started/was in denial about the opiates. Pretty tough putt for the heath care provider when that's what's coming in the door. The difficulty is the frequent back and forth. If it's someone with say a fracture then they get the good stuff, and generally a lot more than what I would give a non addicted person (tolerance) and I'm ok with that. If it's someone with say a pneumonia, it will start with nursing paging me that they want something with pain. I'll order Tylenol. I get paged back later, the Tylenol isn't working, i'll give some naproxen. Page back that's not working. I explain no opioids. I get called in. Lots of anger directed at me, still no opioids. Often there's threats that they'll leave the hospital against medical advice unless they get the pain meds they want. Or you get people who really love to game the system. They'll come in with idiopathic pain that has nothing on labs or exam or imaging that can prove or disprove it. They'll know magic words for admission like vomiting blood or can't eat or drink at all. Then comes the strategic allergies. It's always toradol, tramadol, zofran, codeine, and morphine. Leaving dilaudid and phenergan for nausea and pain. It's super hard not to project onto people when you know they're gaming you, and when you try and directly but politely address the issue there's an 80ish percent chance they'll rain a stream of drama down on you while you have 10 other patients you could be seeing instead.
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Apr 4, 2016 15:05
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Rhandhali posted:How's HB-1 and mandatory KASPER working out? That's a really tough question that we probably won't be able to answer for a decade or so. So my take is that heroin use has gone way up because recreational pills are becoming prohibitively hard to get due to KASPER. On the flip side, I'm hoping heroin use overall will go way down in time because most people get on heroin because they first got addicted to pills which is becoming a lot harder now.
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Apr 4, 2016 15:36
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pangstrom posted:This is going to vary by situation and the doctor, but how often do you suspect the person is an addict, how often are you like pretty sure, and how often are you basically positive? Fair enough, my choice of words was very poor. So when I see things like strategic allergies that no human on earth could possibly have, that's a pretty big tell. Familiarity with pain meds for someone without a chronic condition or history of acutely painful conditions necessitating them is another. The ER history is another. Urine drug screens that contradict patient history is another. Often times you can see track marks on them. Generally speaking I don't let addiction history steer my pain management. If I would give someone with no addiction history morphine or dilaudid, I'd give it to addicted people. The problem is always the inverse. People angry that I won't give them dilaudid for things I would give no one dilaudid for. I'm not going to claim that addiction is a moral failing but some of the behaviors it manifests makes my job a lot harder and more dangerous. Take for instance the people claiming to be vomiting blood. Sure I know that they've had 6 negative endoscopies, capsule studies etc in the past 6 months. But do I want to risk their life on it and not do yet another thorough workup? Those workups have risks on their own terms, what if endoscopy number 7 causes an esophageal perforation and they die?
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Apr 4, 2016 15:51
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My Imaginary GF posted:Sounds like a desperate need for some tort reforms so that you can deny an addict another useless medical test which wastes everyone's time and money. The problem I run into is that the boy who cried wolf isn't an aspirational story for doctors. Turns out doing IV drugs is super bad for you and just because you didn't have a bleeding gastric ulcer or varices doesn't mean you won't get one. I always work everything up at face value because I've seen people who have been to the ED 40 times in a year for abdominal pain, but actually had appendicitis on the 41st time. I'm genuinely working theses things up by the book not out of some abstract fear of lawsuits, but because I don't want to let someone die.
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Apr 4, 2016 18:09
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BarbarianElephant posted:Once when I was about 20 I went to the doctor for some minor malady. The doctor gave me a stern glare and told me "I know what you are looking for young lady, and you won't get it from me!" You might have been profiled. Some health care people are really asses about tattoos.
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Apr 4, 2016 18:32
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My Imaginary GF posted:Are you denying that doctors have bias, and that a system which emphasizes a paternalistic treatment of patients is more susceptible to practitioner bias than one which emphasizes a client-provider relation? I think Jabby's point is that physicians in the UK are less beholden to the "service industry" expectations of US doctors. I fight the good fight every day to appropriately treat pain however there's always the little devil on your shoulder saying "be a candy man! you'll save yourself tons of pages all hours of the days, your patients will be nicer to you, you'll get home sooner, and you'll get paid more because your CAHPS score will go up!" A UK style health care system removes a lot of that. There's a huge part of me that really hopes that the new FDA recs on no opioids for non cancer chronic pain somehow grows teeth. My life would be so much easier if I could just shrug my shoulders and say "nope, can't do that. It's illegal!" Bias wise, US physicians definitely treat different patients differently. I know that African American patients get way more urine drug screens then their white counterparts, or that they get less of the strong stuff. There's definitely a strong component of framing female patients as personality disorder related stuff too.
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Apr 7, 2016 18:59
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My Imaginary GF posted:And my point is, in the NHS, such bias is amplified. We already have enough bias in client-practitioner relations as it stands in America, we don't need more by reverting back to the paternalistic methods of healthcare provision we used to have, we need less. All of the bias I see is more or less subconscious on an individual provider basis. It's not doctors who swap white coats out for white sheets at home, just a general reflection our subconscious racial perceptions. Having a more top down approach to medical care won't result in adding for ethnicity and income bracket on the UDS algorithm.
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Apr 7, 2016 19:10
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| # ¿ May 6, 2024 15:26 |
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blackguy32 posted:Sickle cell is one of the biggest reasons people come in for pain on my floor and since it's primarily an African disease, you know how that turns out. But yeah, many people's expectations of pain relief is unrealistic. And it gets to be a problem when it comes to weaning them off to oral medications because many just straight up refuse to take them and of course in the name of customer satisfaction, hospitals are willing to oblige them and give the pt what they want. Sickle cell is one of those things where I just ask the patient what they want for pain and if it's not criminally dangerous I give it to them. The notion that someone can have crippling pain episodes for their entire lives and NOT get a dependence or high tolerance is pretty crazy to me. Always bugged me in residency when people would talk poo poo about them being addicts. You wouldn't hold up half as well in their shoes.
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Apr 8, 2016 15:51
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