My Very First Narcotics Prescription

It is Monday, August 24, my first day as an attending physician on the general medicine service in a large urban teaching hospital. Believe it or not, I just finished my residency training 2 months ago and my internal medicine board examination last Thursday. What are my responsibilities? Will my patients think that I am too young to be an attending? Do I have the knowledge and skills to lead a team? Should I bring a clipboard to take notes or should I just bring a cup of coffee?

I am somewhat put at ease by the senior residents before the morning attending round. They inform me that our team has 3 new admissions and 15 old patients to see in 2 hours. “We need to be efficient and let's not spend too much time with any single patient. The morning report has to start at 10:30 am sharp,” I am told. The first week flies by and I am pleased that my patients appear reasonable and my residents seem to be on top of things.

The first patient during my second week is a 26-year-old female with a chief complaint of right flank, abdominal, and groin pain. She is admitted through the emergency department for pain control. Her physical examination, which includes a thorough neurologic examination, is fairly unremarkable. Her computed tomography (CT) scan and transvaginal ultrasound are negative for intra-abdominal and pelvic pathologies. “It is probably acute lumbar strain. She needs aggressive physical therapy, anti-inflammatory medications, and pain control,” says my intern during his morning presentation. I agree, it sounds like an easy case and perhaps she does not even need to be admitted.

During the ensuing few days, we have trouble controlling her pain: first with nonsteroidal anti-inflammatory drugs (NSAIDs), then with Percocet® (Endo Pharmaceuticals, Chadds Ford, PA) and morphine, along with adjuvants such as ice, acetaminophen, and muscle relaxants. Finally, she is on a heavy dose of intravenous hydromorphone 4–6 mg every 3 hours with reasonable pain relief. She then refuses to take oral equivalents of intravenous hydromorphone stating, “The pills just do not work as well as the injection,” and tells us that she cannot walk or go home because, “It hurts too much with this shooting pain down my leg.” Her physical examination is unchanged with no new neurologic findings. We proceed to have a magnetic resonance imaging (MRI) of the lumbar spine to rule out spinal stenosis or lumbar radiculopathy, and a noncontrast CT of her abdomen and pelvis to rule out nephrolithiasis, both of which return negative. A few more days pass and she finally agrees to go home on a heavy oral regimen of narcotics. “Dr. Lin, we need your DEA number to prescribe her hydromorphone. Thirty days all right?” My intern asks. “No problem. Please also make sure that she is set up with a new primary care physician.” I reply.

A few days later, she is readmitted to my service for the same complaint, right flank and leg pain, and she apparently has already used up all the hydromorphone I prescribed in just a few days! Do I miss something here? A full physical examination is again normal, so is the repeat x-ray, CT scan, and ultrasound of the leg. Again, she requires escalating doses of intravenous hydromorphone for pain relief. House staff and nursing staff are becoming suspicious: “She is a narcotic seeker. We should get her out as we are not doing anything for her here,” the case manager and patient care director suggest. Slowly trickling in are reports of her being completely ambulatory and normal at night, having inconsistent pain location and severity, frequent splitting among team members and staff, insisting on intravenous narcotics, and finally, the reluctance to go home. “You have to lead this Dr. Lin, I don't think any of us can handle her,” say my residents.

In the following days, we try several strategies to resolve the dilemma. We confront her as a team to avoid splitting. We tell her that no organic cause of her pain has been found, that we will transition her intravenous narcotics to oral regimen, and that we will proceed to subacute rehab placement for her. Pain Management Service is consulted and she is given a hydromorphone patient controlled analgesia (PCA), which she uses sparingly. The case manager, social worker, nursing staff, and I speak with her about the inconsistent pain behavior, unreasonable demands, and abusive attitude. All of these are met with her anger, frank denial, and emotional outbursts.

Patient Service is called and accusations are made against some members of my team for inappropriate touching and language, as well as the perception that I am trying to push her out of the hospital. “What am I supposed to do?” I tell the Patient Service representative, “I think she is a drug addict and, everyone else thinks she is too. How can you believe a word she says to you?” We attempt to have Psychiatry help us with her addiction problem but she refuses to cooperate. We officially discharge her but she appeals and stays for another 3 days on my service.

During the morning round on the day she leaves, I walk into her room, ask her how her breakfast is, and then ramble on about taking the pain medications along with stool softeners. She interrupts me, looks me right in the eye and says, “Doc, even though you try to be nice and calm, and try to smile, I can feel your disdain because you think I am a drug addict. You cannot hide your feelings, you are just too young.” Maybe she is right and I am certainly happy to see her go, now with a larger prescription of narcotics.

Two days later, I get a phone call from a local CVS pharmacy asking me to verify the large amount of narcotics I prescribed for her. The pharmacist politely asks me whether I intend to give her this much. She tells me that the patient had been filling many narcotics prescriptions from primary care physicians, emergency department physicians, and pain specialists around the city and that she turns around and sells them on the street. The pharmacist claims that she has witnessed it. I can certainly feel the anger boiling inside me and the regret that I even wrote that prescription. How can I not see this? How can I continue to fuel this type of activity? I decide to cancel all of the prescriptions at once—I am going to end it right here, right now.

One week later, I am surprised to see her back on my service, readmitted again for pain and running out of narcotics. After a routine history and physical examination indicating no significant changes, I tell her that we will discharge her without any narcotics prescription. She does not say much but wants to leave the next day when her mother can come to pick her up. I agree and stand my ground by not giving her any narcotics while she is in house. I tell her, “I believe that you are not in significant pain, as you do not have tachycardia or elevated blood pressure, and we will only give you Tylenol® (McNEIL-PPC, Inc., Skillman, NJ) or ibuprophen for pain. NO NARCOTICS!”

The next morning, she develops severe nausea, vomiting, low-grade fever, sweating, and despite antiemetics and supportive care, she is not able to go home. She is experiencing severe symptoms of narcotics withdrawal. She requires low-dose intravenous narcotics and then tapering oral narcotics to go home with. I have no choice but to write her another narcotics prescription.

She does not come back to my hospital nor do I hear anything about her again, but my residents, physician assistant, and I still share her story.

“She surely knew how to manipulate the system and the doctors,” say my residents and physician assistant, “You did a good job for a new attending!”

“Thanks for the support. She is a tough case,” I reply.

I have since written many more narcotics prescriptions. It is powerful to know that with these pain medications, my patients' suffering will be relieved at home. But just like Spiderman eventually finds out for himself, any kind of power, medicine included, comes with great responsibilities.