Breaking Bad: drug dealing the hospital way

It’s funny, a common discussion point comes up every so often when I talk to my non-medical friends about careers. The access to strong medications and drugs seems to be an endless fascination for some people;

Can you write me a script for some good sleeping tablets as I don’t sleep well on flights?; Any chance of a decent painkiller for my old rugby injury; I’ve tried tramadol and it doesn’t work….

Constant questioning and requests, sometimes I feel like a mere dispensary for the needs of my friends. It is one thing of which I am very cautious and always administer to friends as a professional, they know at this stage not to casually ask for sleepers! This pressure sometimes to hand out tablets like sweets can be hard to bat away, however we need to constantly think about the rationale of why they need, and more importantly, why they don’t need, the 20mg of oxycodone for a sore knee.

I got “played” recently, as so many doctors and nurses do, and I am fairly confident (and secretly hopeful) that most among us will be similarly duped at some point in our careers. Picture this: a young girl in her twenties, frail looking, very short of breath, explaining that she is having a pulmonary embolism similar to one she has had before. After discussing her risk factors, examining her, observing her heart rate (134bpm) and oxygen saturation (94% on room air). I felt there was indeed a high likelihood that she was suffering from a pulmonary embolism.

As she writhed around in pain, I of course acted to help her, popped in a cannula and immediately gave her some fentanyl having considered her allergies to other agents. Soon enough, the clerks appeared with her old notes and after only a brief glance, I was kicking myself. This lady was a known drug seeker and I, the mug here, gave her the hit she so desperately craved. I can easily admit, not my finest moment. After refusing to give her anymore she simply took out her drip and carried on out of the department, maybe even heading to the next hospital (not unheard of) to play on the next unsuspecting and naïve doctor with a charming Irish accent.

I am not so doe-eyed, however, that the concept of drug seekers is completely alien to me, I know about drug seeking behaviour and I have come across it before. I think what really struck me about this particular patient was how manipulative she was, even going as far to research complex medical conditions and gaining knowledge of individual consultants working in the hospital so as to appear the genuine article. This one completely hoodwinked me and made me realize that these people will go to extraordinary lengths and don’t always appear as the stereotypical disheveled, homeless “druggie” we might expect. Notably, this lady had never taken illegal street drugs, this was exclusively an addiction to prescription medication, only accessible by having doctors prescribe it!

I know that illegal drugs are pervasive in society, and God knows we see the effects of them in the Emergency Department; but something which I’m starting to appreciate as I continue to meander through this career, is the potential to feed drug addiction in the community from a resuscitation bay or a General Practitioners consulting room. Particularly in my early days as an intern I can admit I was a bit lenient with my medication prescribing. This was in the context of being a busy intern-on-call, running around for up to 30 hours without sleep and being asked to chart painkillers for patients on the fly. Having been assured during my corridor consult that paracetamol does not work for the patient, as a reflex I would chart Oxycodone 5mg up to 4 times a day. Why did I do this? Because I simply did not have the energy to argue nor to go and question the patient myself as inevitably a urinary catheterization and several impatient nurses awaited two wards away.

With time, I have become a ‘hard’ prescriber and I believe this is due to seeing how people respond to these medications of abuse and the potential for addiction in the flesh, that I can appreciate what I am prescribing. It’s all well and good being told by a crusty old pharmacology lecturer with a body odour issue that some drugs are addictive, it only really hit home with me after 3 years of seeing these cases myself and getting a feel for who is seeking and who is not. That said, we all still get caught out as I have illustrated with my recent escapade. I think its fair to say that we should be tough with our prescribing. Some doctors I know take a very hard-line approach, refusing to prescribe certain medications with addictive properties.

Now this ‘no tolerance’ approach to the administration of drugs doesn’t come without its own disadvantages. The whole reason why we have the drugs is because they might be needed. For example, when that 50-year-old patient comes in with genuine back pain that they never had before; “It’s like childbirth doc!” The last thing I want to find myself doing is always questioning the legitimacy of their claim (although Joe Bloggs may want to rethink the way he describes his pain to the triage nurse, herself a mother of 3 – including twins). Is a hard-line approach the best way to deal with this? After all, they came to the Emergency Department in desperation to have their pain managed. If they genuinely need the strong stuff, then surely it is merited. The concern is whether or not we are actually creating the addicts by simply not being au fait with the medications, throwing around opiates and benzodiazepines like M&Ms at a 5 year olds birthday party. We are feeding a new type of drug problem. Fans of the TV Show “House” will recall his love of Vicodin, arguably caused because it was given to him without question in the early days of his leg pain, to the point where he ended up traveling to nearby hospitals giving fake names to procure a script. Seeing addicts like House and my patient, a case could be made for a universal blanket ban on addictive medications.

Considering both sides of the argument, I believe we need to practice with caution. Of course we must think of the potential pitfalls with what we give our patients, but we must never forget why they may need it. Addiction is something preventable by careful medical prescribing and is something that should be just kept in mind when we write that script for diazepam or oxycodone. Do they really need it? What harm can come of it? As is often quoted, healthcare professionals shall firstly ‘do no harm’; here is an aspect of our practice where there is potential to harm. Simply taking the easy way out and giving the patient what they ask for can lead them down the slippery slopeof drug seeking. However we should also bear in mind that the majority of people are genuine with real conditions that will require medications to ease them through the burdens that are in their life. They may indeed require the benzodiazepines to ease their longstanding social anxiety, and the chronic back pain due to displaced discs may only eased with a fentanyl patch. It is, after all, the reason that we have the medications available; to use then when we need them.

To think back to my patient from earlier, would I have done anything differently? I admit that I should have thought of drug seeking more than I did, however, given the information available at the time; I would not change my management. My rationale behind this is that my job is primarily to ease suffering and tie down a diagnosis with the information given to me by the patient and my clinical examination. A clinician simply cant wait to see if someone is a drug seeker in the emergency situation, its easy being wise later, but I am not prepared to let unwell people suffer for 10 minutes while I go and check notes for potential opiate addiction. I do not want to become someone who cynically second-guesses everyone’s intentions. Although wrong at times, I like to think that the majority of people seek our help with genuine issues. The minute that you lose faith in human nature is the minute you stop being human yourself. This is why I prefer seeing Grannies with fractured hips; these stoic old ladies usually just need some paracetamol, a femoral nerve bock and an ear to listen about Beatrice winning the bingo last night on ‘walking sticks 77’. The irony certainly makes me laugh, ‘cause if you didn’t laugh, you’d cry.