15 January 2013

Mayor Bloomberg and Narcotics

I may be just a bit late in commenting on this, but last week (which was like ten years ago in Internet time) there was a bit of hue and cry regarding Mayor Bloomberg's report on the matter of prescription drug abuse and restrictions on new prescriptions for painkillers through the Emergency Department.

Initially, I was concerned. I completely agree with the comment from the linked article: “Here is my problem with legislative medicine,” said Dr. Alex Rosenau, president-elect of the American College of Emergency Physicians... “It prevents me from being a professional and using my judgment.” The verbiage used regarding the new rules was worrisome: restricted sharply... city policy ... will not be dispensed ... regulatory authority to impose, and the like.

I'm like most doctors in that even when I agree with the purpose of proposed rules, I quite object to interference in how I practice, to "the government coming between you and your doctor" as it was so memorably put in the past. And given that Bloomberg is getting something of a reputation for being a little dictator I was all ready to get my pitchfork and torches and head down to join the mob.

While I was getting my outrage machine up to operating temperature, I took a moment to read the official press release and the actual source document (PDF), though, and one word in the very first paragraph, notably absent from the press coverage of the proposal, jumped out at me:


Well, that's a horse of a different color, isn't it? Doctors and hospitals are encouraged but not obligated to follow the new guidelines, and in individual cases, the doctor can freely exercise his or her judgement. I'm good with that. So what about the meat of the policy?

Key points that jumped out at me:

  • A new/improved database for tracking narcotic prescriptions and making it available to prescribing doctors.
  • Not prescribing more than a 3-day supply of most narcotics, and not at all prescribing oxycontin, fentanyl or methadone through the ER, and not refilling these meds
  • All narcotics to be electronically prescribed (to limit forged prescriptions)
  • Changing the defaults on EMRs to have lower amounts of tablets dispensed.

Frankly, these all seem reasonable, as long as physician discretion is preserved. If someone has a long-bone fracture and won't be into see ortho for a week, well then a week's worth of pain meds is reasonable, for example. In our state, we put forth some very similar guidelines in our "Seven best Practices" for reducing ER overuse and abuse.

The "guidelines" are particularly useful for a practicing doc in that it gives you permission to say "no." Currently, if I see a patient whom I suspect is "working me" for narcotics, but I don't have clear evidence to support that suspicion, I am in a bit of a bind. In such cases, there's no objective evidence of disease — back pain, neuropathy, etc — but that doesn't mean there isn't real pain. If I say no, I run the risk of patient complaints and a letter from the CEO. If I say yes, I then get bogged down in negotiations over how much and what drug. The guidelines offer a compromise: a limited supply of less potent meds. If the patient ups the ante or tries to demand more, I can point to the guidelines and explain that we have a policy, that it's not personal or judgmental, but is simply our "best practice." Even better is that there are clear guidelines against refills and treating of chronic non-cancer pain in the ER.  All this is meant to give doctors faced with a demand for narcotics the institutional backing to say no, and tacitly recognizes the fact that doctors have been complicit in creating the problem through excessive opiate use.

I note that endorsing the proposal in NYC was the New York chapter of ACEP, which is also heartening. The problem of ER abuse and prescription narcotic addiction/diversion is a real issue, and it is growing. We, as ER physicians, need to take ownership of the problem, as much as we can, and take leadership in developing measures to mitigate the problem. If we don't, then it is predictable that someone else, likely state governments, will come in and impose solutions on us -- and those "solutions" are likely to be heavy-handed, draconian, and probably ineffective.

So. from what I can tell, New York's approach seems very well-reasoned and hopefully pretty effective. I am also encouraged by an addendum that several private hospitals in the NYC area have announced that they are also going to follow these guidelines (which properly only apply to city-owned hospitals). I'm also particularly pleased that the process we went through in our state has begun to be used as a model for other states to follow!

14 January 2013

Apparently I'm a pimp

I actually have no interest in responding to this. I decided some time ago that life is too damn short to waste it arguing with assholes on the internet. I've stuck to that reasonably well, and been happier for it. But since I have been personally named I suppose I should give it a perfunctory response. That's all it deserves.

I wouldn't bother at all, in fact, if it weren't for the steaming mass of ad hominem attacks piled on top of it. But that's his style: he uses strawman arguments and personal insults to obscure fuzzy thinking. Apparently, in the minds of the free-market, anti-government zealots out there, if I support expanded government funding and regulation of health care insurance, which I long have and still do, then I may never ever criticize or disagree with anything the government does. 

That's the mindset of an ideologue: purity above all else. You are for the government or you are for the private market. It’s an either-or, absolutist position. You cannot logically have a nuanced view or a pragmatic approach: that’s unpossible! 

Clearly, there’s no point in discussing anything with this sort of person, so I won’t bother. But I will make one point — just one point — in rebuttal. The worst abuses I have encountered, thus far, have been by private, not governmental actors. Contracted Medicare carriers and insurance companies have been far more aggressive in trying to exploit the logical catch-22 in the medical necessity rules. For those who say they fear the government intruding into medical care, I agree it’s a fair point. But given their financial incentives and lack of ethics, I will always fear the private insurers even more.

13 January 2013