JOHN SHUFELDT, MD, JD, MBA, FACEP
The hard core rockers amongst us know that Sister Morphine was written and recorded by Marianne Faithful while she was dating Mick Jagger during the time he and the Stones were recording Let it Bleed in 1969. Marianne’s version tanked early, but the song was later covered by the Stone and received more acclaim. Parenthetically, she did not receive credit until the Stones’ 1998 No Security album.
The song (I believe) is about a man who is hospitalized after a car accident and dies while demanding more narcotics. Allegedly, some of the lyrics were inspired by Keith Richard’s girlfriend who, during her own hospitalization, was given narcotics.
Sister Morphine (First and last verse)
Here I lie in my hospital bed
Tell me, Sister Morphine, when are you coming round again?
Oh, I don’t think I can wait that long
Oh you see that I’m not that strong
Sweet cousin cocaine, lay your cool hands on my head
Ah come on, Sister Morphine, you better make up my bed
‘Cause you know and I know in the morning I’ll be dead
You can sit around and you can watch all the clean white sheets stained red.
The term “narcotic” is believed to have been used first by Galen in reference to agents that cause numbing or deadening. The word is based upon a Greek term used by Hippocrates to describe the process of causing an altered state of numbness.
Abuse of prescription painkillers is at an all-time high. In 2010, more than 12 million people reported using prescription painkillers for “non-medical” reasons. Prescription narcotics were responsible for 475,000 emergency department (ED) visits and more than 15,000 deaths. Cast in a different light, for every death, there are 10 individuals in treatment for narcotic abuse, 32 ED visits for misuse or abuse, 130 people who are narcotic-dependent, and 825 people who are using narcotics for nonmedical reasons.
The explosion of narcotic abuse is, of course, also a huge issue for medical professionals. For example, Dr. Hsiu-Ying Teng, a physician in Rowland Heights, California, has been charged with second-degree murder following the deaths due to overdose of three of her patients. If convicted, she faces a sentence of 45 years to life.
Prosecutors hope to prove that Dr. Teng – nicknamed “Dr. Feelgood” – has a long history of over-prescribing medications and that her prescribing habits were directly responsible for the deaths of three of her patients. Allegedly, she was writing prescriptions foe Xanax, OxyContin, Vicodin, and Adderall at a rate far greater than other providers. Apparently the California Medical Board and the Drug Enforcement Administration believe that she has written more than 27,000 prescriptions over 3 years. Assuming she works 240 days per calendar year, she is writing 37 prescriptions per day for the medications above.
In Arizona, a physician’s license was revoked for inappropriate prescribing habits that may have led to the death of his patient. The Arizona Medical Board found that the physician had a recurring pattern of prescribing large amounts of opioid pain medication and Soma without sufficient historical, physical or imaging data.
If your state is anything like Arizona, I suspect that even a cursory search of the physician databank would show a trend of adverse actions of physicians’ licenses surrounding overprescribing and personal use of opioid and other addictive medications. This increased scrutiny is on top of an already-addicted and demanding patient population who travel from provider to provider demanding help. Not all patients are addicted; some are simply selling the medication on the street as a way to support themselves. A quick Google search revealed that the price on the street for Vicodin 5/500 is $1 to $2 per pill and the price of Oxycontin 10 mg is $5 to $10 per pill. I have heard that in some areas, the street price is much higher.
In the ED, we have become very accustomed to patients demanding narcotics. We have set up pain protocols for patients and use an Arizona-specific pharmacy database to see how many prescriptions a patient has filled and from how many different providers. I routinely ask, “Have you seen any other providers who have given you narcotic prescriptions?” The look on patients’ faces is always priceless when I come back with two or three pages revealing multiple narcotic scripts after they have denied receiving other prescriptions. Nine times out of 10, the answer is, “someone stole my identity.” In some cases, that has actually happened. When I hear that response, I always insist upon calling the police to report the identity theft and that someone is obtaining narcotics fraudulently.
This issue is so prevalent in EDs and we are so accustomed to dealing with it that I suspect urgent care centers will be an even bigger target than they are already for those sorry individuals who are addicted or who support themselves by selling prescription pain meds.
Here is how you can protect yourself:
- Confirm the patient’s identity: I have personally discovered numerous instances where patients (or pretend patients) have fraudulent identification under which they try to obtain narcotics. The most comical one was a patient who was clearly of Hispanic origin who was using the driver’s license of a person who was clearly of Asian descent.
- Request and review past medical records: Reportedly, patients are now even forging magnetic resonance imaging (MRI) and computed tomography results that demonstrate significant pathology necessitating narcotics. Beware of entrepreneurs with significant pathology documented on their MRI reports who are redacting their names and selling their results!
- Take and document a thorough history: Often time, under direct questioning, a patient’s story will start to unravel and he or she will become rattled and reveal his or her true intent.
- Perform and document a complete physical: It is hard to fake pathology. A thorough exam often detects malingerers.
- Beware of doctor hoppers: Be more discriminating about your prescribing habits. Not all “doctor-hoppers” are trying to obtain narcotics fraudulently but some are, so have your guard up.
- Be on your guard with last-minute patients and out-of-state patients: I have found, over the years, that patients who arrive 1 minute before the doors are locked often do so very purposely, hoping that you will simply prescribe them something quickly so that you can get out on time. Narcotics abusers will also cross state lines to obtain drugs.
- Limit the number of pills and refills: I have seen multiple instances where providers have written Lortab 7.5/500 1-2 q6 #90 with 5 refills. BFRF!!! (Big F—ing Red Flag!).
- Never prescribe narcotics for family members: State laws vary, but in general, never prescribe narcotics or other Schedule 2 medications for family members. I have two clients who prescribed for their wives. When they got divorced, their jilted spouses notified the medical board and the board asked for the former spouses medical records. One of the physicians created the records, back-dated the page, signed it and turned it in!
The bottom line
Patients should never be denied appropriate pain medication for their conditions. It’s determining their actual condition that can be challenging. Never write the phrase “drug seeker” on the medical record. Documenting “pain out of proportion to history or physical exam findings” alerts subsequent readers while protecting you from appearing uncaring.
Document as thoroughly as possible and get informed consent from patients regarding their pain medication in words such as these: “We will absolutely treat your pain. Your medical records show that you have received multiple prescriptions for Percocet, which clearly is not working. I am concerned that you are starting to develop a tolerance to this medication, so I will not be giving you narcotics for your pain. Instead, we will be treating you with XXXX.”
Or, sometimes I simply start singing the Jefferson Airplane song:
One pill makes you larger
And one pill makes you small
And the ones that mother gives you
Don’t do anything at all
Go ask Alice, when she’s ten feet tall.
If my informed consent soliloquy does not cause patients to run out the door, my falsetto singing often does!
Bibliography
Cathy McKitrick. Youth’s overdose sends strong message. Salt Lake City Tribune 2011 May 17. Available from URL: http://www.sltrib.com/sltrib/news/51689248-78/prescription-drugs-drug-watson/html.csp.
CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. MMWR. 2011; 60: 1-6.
CDC. Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States. 1996-2006. NCHS Data Brief; 22 Sept 2009. Available from URL: http://www.cdc.gov/nchs/data/databriefs/db22.pdf.
Keith O’Brien. Man fights what son could not. Boston Globe 2008 Jan 12. Available from URL: http://www.boston.com/news/local/articles/2208/01/12/man_fights_what_son_could_not/.
National Vital Statistics System. Drug overdose rates by state. 2008.
Substance Abuse and Mental Health Services Administration. Substance abuse treatment admissions by primary substance of abuse, according to sex, age, group, race, and ethnicity 2009 (Treatment Episode Data Set). Available from URL: http://www.dasis.samhsa.gov/webt/quicklink/US09.htm.
Valarie Honeycutt Spears. Ky. sees rise in overdose deaths from pills obtained in Fla. Lexington Herald-Leader 2009 Apr 12. Available form URL: http://www.kentucky.com/2009/04/12/75884/ky-sees-rise-in-overdose-deaths.html.
Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SRB. Characteristics of opioid prescriptions in 2009. JAMA. 2011; 305(13): 1299-1301.
