“If you don’t give me the prescriptions, I’ll be in your emergency room tomorrow.”
This was the ultimatum from a patient admitted to the general medical ward for symptoms of opiate withdrawal. He was a middle-aged man with chronic headaches who had been prescribed large doses of long- and short-acting morphine for years by a physician who had since discharged him from his practice. He had seen two other providers who would not prescribe the medications for him and he had run out. He presented to the emergency room with nausea, vomiting, diarrhea and pain, secondary to withdrawal.
Given that he had no current physician who would continue to prescribe him these medications, and his pattern of narcotics dependency documented in the chart, and which I confirmed in conversations with his previous providers, my initial plan was to discharge him, post-taper, without any narcotics. He had no other medical issues that required hospitalization.
I offered him supportive medications to treat his symptoms of withdrawal, but he declined. As the junior resident on the team, responsible for disposition of patients and with the constant pressure of bed scarcity weighing on me day in and day out, I felt that he needed to be discharged. Needless to say, he did not agree with this plan.
Chronic pain is a widespread medical problem and results in billions of dollars in direct and indirect medical and nonmedical costs. According to some estimates, 75 million Americans have chronic pain, unrelated to cancer, and stable doses of opiates can be effective at managing the pain and improving functional status. Unfortunately, these medications can result in dependence, as was the case for this patient; the doses prescribed to him by other physicians had escalated over the years. In my outpatient clinic, I have few patients on narcotics, and there are clear rules, either through “pain contracts” or explicit expectations reinforced at each appointment, about the conditions that must be met in order for me to continue to prescribe them.
So, what to do? This was a patient who basically refused to leave the hospital without pain medications. There was no good plan in place to address his chemical dependency and his chronic pain. I had no doubt that he had pain and probably had a lower pain threshold given his years of opiate use. Yet would I be doing him a disservice in perpetuating the problem by prescribing opiates? And what was my obligation to free up a bed since the emergency department was filled with sick patients who really needed one?
In the end, we decided as a team that discharging the patient from the hospital that night was the best result that we could hope for. So we compromised. He had an appointment with a resident physician who was to become his new primary care doctor set up at the end of the month. We sent him out with half of his normal doses of opiates and documented the course of care extensively in the medical record, alerting future healthcare providers about the nature of his illness and the steps we had taken to get him the help he needed.
It was not a very satisfying solution, and I was unsettled afterwards, debating whether or not we had done the right thing. I asked a fellow resident. The two of us shared stories of difficult decisions and agreed that, in this case, there was probably no “right” answer. But we hoped that, with the help of his new doctor, the patient might be able to address his chronic pain with fewer narcotics.
Erica Seiguer Shenoy, MD–PhD ’07, is a resident in internal medicine at Massachusetts General Hospital.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions or Harvard University.
