Picking up the pieces

At home I'm usually surrounded by a mess of toys. With 2 toddlers running around, the floor is littered with knick knacks and my evenings are spent picking it all up. It's challenging, sometimes frustrating but I know with time and education, they will learn and it will change.

I'm often doing the same thing at work. Patients come with their internal home littered with problems that my residents are constantly trying to correct and pick up after. In this era of chronic illness, this is a challenging and sometimes frustrating endeavor. But with medical expertise and a partnership with the patient, many of these problems can be fixed.

But there are some things in medicine that are extremely difficult to "pick up" after. The most difficult one is the chronic pain, opiate dependent patient. This group of patients has become an albatross for too many primary care physicians. There are many unfortunate reasons for this.

Like most problems in our healthcare system, it begins with the system itself. Simply put, when you don't have insurance and access to healthcare, it's very difficult to get well. With chronic illnesses like diabetes, high blood pressure and obesity, they can be managed (albeit sub-optimally) without insurance. We can see these patients every few months and work around the limitations of insurance. We can easily switch medicines to more cost effective ones. Patients are usually pretty adaptable to medication changes with these conditions.

When a chronic pain opiate dependent patient doesn't have insurance, it's a real quagmire. First, they need to come monthly for assessments and refills. With such potent potentially addictive medicines, monthly visits are appropriate and the standard of care I advocate in our resident training clinic. Without insurance, monthly appointments become expensive and patients get frustrated. Secondly, changing or even stopping the medicines is extremely challenging. This drug class creates a level of dependency similar to how Frodo Baggins felt towards the one ring of power in Lord of the Rings. It is impossibly hard to change or let go.Thirdly, without insurance its very difficult to do urine drug screens  (expensive!) which is rapidly becoming the standard of care in managing this group of patients.

The insurance problem also highlights an issue with accountability with chronic pain opiate dependent patients. I'm constantly seeing patients who've recently lost their insurance or their doctors stopped taking whatever insurance they have. This is not unusual these days. If they were on a brand name drug for cholesterol, I can easily switch to a generic. If they were on a medication that I thought was unnecessary, I can easily stop it. But when a doctor creates an opiate dependent patient then essentially dumps them because of their insurance, I have serious issues with this. It's just wrong. The ethics and morality issues in this scenario are honestly better explained by Mary Shelley's Frankenstein than my little blog.

Besides the insurance angle to this problem, I won't even get into misguided guidelines created in the 1990's by specialists and drug companies that touted the safety of opiate medications for non-cancer pain.

When you combine such realities together, you get patients with many chronic illnesses without proper access to care, hopelessly dependent on dubious medications, nowhere to go except the overwhelmed safety net that is primary care.

A litany of toys in my living room is just not acceptable. I pick it up, optimistic that eventually it won't be a mess anymore. And with that same smile and vigor, I (we) pick up the pieces of our patients, working and waiting for the system and our patients to get healthier.


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