Hi. I’m a 44-year old emergency physician. And I’m an addict.

My addiction came to light when my Press Ganey scores plummeted after I started to stand up to the chronic pain and frequent ER patients.

The fact that I have an addiction was reaffirmed when I went to my state’s Prescription Drug Abuse Summit. When I saw so many professionals from varying fields (medicine, law enforcement, pharmacy, education) assembled, I realized my problem: I’m addicted to prescribing pain medications.

As with any addiction, the first step in treatment requires acknowledgement of the problem.

I thought back to how my addiction began.

Coming out of medical school, there is a certain power that comes on the first day of residency. You suddenly have the power of the pen. You can write prescriptions for low blood pressure, high blood pressure, low blood sugar, high blood sugar, too many bowel movements, not enough bowel movements.  The list goes on and on. But one of the largest ways in which we can help patients is by treating their pain. Controlled substances. Yes, the new physician quickly learns that the pen wields an awesome power and an awesome responsibility. This feeling fades quickly in the face of an 80+ hour work week.

Fast forward 5-10 years. You are seeing 10-12 patients at the same time, all the chest trauma goes across town, and you have a waiting room that is 20 patients deep, and you already know the medical history of ten patients waiting to be seen on the tracking board.

Hospital administrators pressure you to make sure that all non-emergent patients are treated and released within 90 minutes. All admits must be up to the floors within 240 minutes, if only the medicine consultant would get down and actually see the patient.
It’s not uncommon to see 40 or more patients in a shift. I make it a point to look up the prescription/controlled substance database our state has. This has been an absolute lifesaver to me and to several patients I have confronted.

The problem is that it takes time:

• 2 minutes to look up the patient and print off the list
• another minute to count up the number of prescriptions (it does take time to count to 50 or even 72 – my personal best record for one year)
• another 3-5 minutes to go to the room and confront a patient who has an issue
• then a few more minutes to sit down and document the conversation.

So I have 10 minutes to evaluate a patient, create notes in an arcane electronic medical record, and discharge the patient. Yet all of that time can be taken up by doing what is right with drug seeking patients. I cherish the ability to “catch” someone who is diverting drugs, to be able to sit down with them and have that “aha” moment. I have even had a few patients come back and thank me for confronting them. But my worth is partially measured by the number of patients I see per hour. My worth is also partially measured by my patient satisfaction scores. It’s not all possible.

Why do I and so many other physicians have this addiction? Not providing the prescription is very hard. It takes time to do the research on the patient. Confronting the patient with a problem is emotionally draining. Doing it 5-10 times in one shift is not only a reality, it is downright crippling. It sucks out last bit of energy out of your soul. Rather than confronting patients and arguing, it’s far easier to write a prescription for narcotics and move on to the next patient. This is the mindset of thousands of physicians. Healthcare is different than it was 5-10 years ago.

As soon as I started saying “no” to drug-seeking patients, it was as if I had been liberated. I still have lapses and give out prescriptions to a patient against my better judgement. And I occasionally get burned. I am human and some days I just don’t have the energy to argue and fight with drug seeking patients. As time passes, however, saying “no” gets easier.

Physicians need to start saying “no” once in a while. Take the time to review a patient’s medication history. Don’t be the doctor who prescribes the patient’s 300th Norco tablet of the week. Saying “no” just once a day can be liberating. Try it just once a day for a month. Then twice a day. It gets easier. At first, I actually felt guilty when I wrote for Ultram instead of Vicodin. It has become easier with time.

Physicians can’t fight this addiction alone, though. We need the backing of hospital administrators. Hospital administrators must listen to physicians and see how much of a toll the prescription drug abuse epidemic is taking on patients, the healthcare system, physicians, and the bottom line. How many $500 ER visits will a hospital be willing to write off when they learn the patient just wants 20 Vicodin? Hospitals must stand behind and support physicians who are willing to stand up to drug-seeking patients. Perhaps patient satisfaction scores will take a hit. So be it. Administrators need to take a step back and see the big picture on this one.

Maybe administrators need to be held legally liable for patient overdose deaths when they haven’t created a policy for dealing with medication prescriptions. Sometimes getting sued is the only thing that makes administrators wake up.

So, I’m out of the closet. I am a recovering “controlled substance prescribing addict.”

It feels good to be free of that burden.

Most of the time at least.

This anonymous physician blogs at WhiteCoat’s Call Room at Emergency Physicians Monthly and Dr. Whitecoat.