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Where does it hurt?
March 31, 2012 8:13 PM   Subscribe

Deep vein thrombosis is generally a topic that comes up with regards to airline seating and other periods of prolonged immobility (previously). Anna Brown was a homeless woman and constantly on the move, so doctors in the emergency room thought that her complaints of leg pain were just drug-seeking behavior. Unfortunately, drug seeking is a major problem in ERs in the United States.

Earlier research had already indicated that whites are more likely to be prescribed painkillers in emergency rooms than minorities; one coauthor of that study had suggested that perhaps minorities were simply less likely to complain or to feel they deserved good pain management. When things like DVT are being missed despite repeated visits to different ERs, it's easier to implicate a racial bias in medical care.

How to get around the need to get better care to some without wasting resources? Better, more culturally aware nursing. A shift to more urgent care providers to ease the burden on ERs. Oh, and hopefully that PPACA thing.

(And if you have leg pain, even if you haven't flown lately, don't ignore it.)
posted by gracedissolved (60 comments total) 17 users marked this as a favorite

 
Thanks for a great post. I just heard about Anna Brown earlier today on Democracy now. From the transcript: "The St. Louis police never announced Brown’s death. Her story only came to light six months later after an anonymous caller tipped off the St. Louis Post-Dispatch newspaper."

Here's a link to a the full paper on racial disparities in prescription rates.
posted by compartment at 8:31 PM on March 31, 2012


Pretty horrifying story, I saw this the other day, and thought about how conservatives always say you don't need health insurance because you can always just get the care you need at the E.R.

But, that actually didn't matter in this case: She had medicaid, so, her insurance bills would be paid for.

The other question is whether she would have survived if she'd gotten normal medical care. Had they given her oxycontin and sent her home, would she have lived? It certainly would have been better to die in comfort then on the floor in a jail cell for having tried to get medical care.

It does seem like if she had called 911 after she started having trouble breathing they might have been able to save her. So I don't think you can say for sure she was doomed.

But the basic problem, IMO a medical system that prefers to 'error' on the side of people with legitimate medical problems experience excruciating pain then 'error' on the side of people who are not in pain feeling extra pleasure, even to the extent of prosecuting doctors if they don't make the same decision. Seems like a very bizarre choice.
posted by delmoi at 8:41 PM on March 31, 2012 [13 favorites]


Gosh it sure would be nice if recreational drug users and addicts could safely and legally obtain their fix, rather than confusing the situation in emergency rooms.
posted by kavasa at 8:47 PM on March 31, 2012 [44 favorites]


Maybe get the criminality out of drug abuse, for a start. Some people have problems with wanting drugs too much, can we just recognize that this is something the legal system doesn't need to have a big role in? Can we work out a way for people who want drugs to get them in a safe and controlled way, maybe also present these people with other options for their own long term health and safety?
posted by Meatbomb at 8:47 PM on March 31, 2012 [6 favorites]


So after reading the linked Post-Dispatch article, some pieces fell into place for me re: what happened to Anna Brown: She was at St. Mary's. That's probably the closest hospital to where I live and work—and the last hospital I'd ever want to be taken to under any circumstances.
posted by limeonaire at 8:51 PM on March 31, 2012


It's worth noting that "drug-seeking" is often a sincere attempt to manage real pain. The DEA has just about driven pain management out of existence as a medical specialty.
posted by vorfeed at 8:58 PM on March 31, 2012 [27 favorites]


I'm in chronic pain but I'm a middle class white woman so it's okay to give me drugs. I've honestly had little trouble getting what I need and I shudder to think about the pain I'd have to endure if I couldn't. I completely understand people who do whatever they must. Chronic pain is soul destroying.
posted by desjardins at 9:05 PM on March 31, 2012 [8 favorites]


I was recently in the ER, and there were signs everywhere that they do not renew pain prescriptions.
posted by annsunny at 9:05 PM on March 31, 2012


"Drug-seeking" is still not the barrier to getting actual, effective health care that the stigma and discrimination against drug users are. There are better ways to deal with "drug-seeking" if you really think that that is the problem than by denying sick people health care and actually treatment for actual pain. This poor woman didn't die because she was on drugs; she died because someone stereotyped her as being likely to be on drugs.

And what vorfeed said.
posted by gingerbeer at 9:19 PM on March 31, 2012 [6 favorites]


So this woman had a DVT. In any competent, non-racist hospital, a sprained ankle and persistent pain like that should have suggested a DVT, and she should have been sent for an ultrasound - not a perfect diagnostic tool, but it very likely would have caught the clot. Doing that has nothing to do with handing out pain-killers (and handing out pain-killers is fine by me). It's mere racist incompetence that she was not diagnosed correctly - I've had a calf ultrasound for pain, it's not a rare or difficult procedure.

Also, if we switch over to urgent care instead of the ER - are urgent cares obliged to see you if you don't have insurance? I always thought they were not.
posted by Frowner at 9:30 PM on March 31, 2012 [4 favorites]


Ugh, St. Mary's. Yeah, it's a horrible hospital. I've told the spousal unit that if I'm ever in need of emergency care, take me to Barnes or St. Luke's or St. Anthony's--anywhere but St. Mary's. And I'm not sure why that's the case. I mean, they aren't in a rough part of town and their buildings all look shiny and bright, but my one experience there has put me off them for life. I would categorize the "care" I received as barely competent and callous. And I'm a white middle class woman who was getting an outpatient surgery.

That being said, she had been to two other hospitals in the weeks before going to St. Mary's with no competent diagnosis, so . . .
posted by miss patrish at 9:36 PM on March 31, 2012 [2 favorites]


Like pretty much every health care marker, missed diagnoses or innacurate ones have a racial component to them where African-Americans fare worse.
It can be so tough at points though...we get patients who come into the ER 3-4x/wk and have true chronic problems that might or might warrant admission. Just last week I admitted a patient who came in for abdominal pain 3x in the last week....numerous previous er encounters and discharge summaries showed her to exhibit drug seeking behavior. She had a ridiculous 4-abd Ct scans (and all that radiation) in the last year....but we admitted her on the fourth visit in the last week - basically because we felt sorry for her and lo and behold she had a nasty cdiff diarrhea (needs at least some hospital treatment).....she was just lucky but it's so hard to tell in such patients as to what's real and what's not real - hence the radiation.

I know she had Medicaid but few people take it and it's still hard to get good continuity of care on it....

But yes one solution is a primary care doc who cares and knows you well....not everything has to happen in slammed ERs.

I can only imagine a world where this woman truly felt part of society, where she had a place to go to that would simply not stereotype and dismiss her and say - wow...you know I know she likes narcotics but that leg an just that leg is hurting...that's rare and perhaps it's a bit more swollen than the other...let's rule out a DVT.

The health care despite its faults is going to award such care and give more people access to a saner system (paying for it is another concern but it's wart is in the right place)

I truly hope that amidst all the talk of broccoli and such the justices who all get taxpayer funded healthcare will not overturn it.
posted by skepticallypleased at 9:39 PM on March 31, 2012 [5 favorites]


It does seem like if she had called 911 after she started having trouble breathing they might have been able to save her. So I don't think you can say for sure she was doomed.

I believe she had trouble breathing after she had already been jailed for refusing to leave an ER because she was in pain and wanted treatment. She said her legs hurt too bad to walk, so the cops dragged her into the jail. She died on the floor of her jail cell, alone.

In that circumstance, I think it's safe to say she was doomed, but not by anything she herself failed to do.
posted by emjaybee at 9:48 PM on March 31, 2012 [5 favorites]


Frowner, she did get an ultrasound that didn't show a clot.
posted by desjardins at 9:49 PM on March 31, 2012 [1 favorite]


A few years ago, my wife and I spent 8 hours in the waiting room at George Washington University Hospital (you know, the place they took Reagan when he was shot). Her chest pains weren't enough to get her admitted quickly, and her health insurance didn't make any difference, either. She was eventually seen. First, they said she had gall stones, despite the fact that her gall bladder had been removed. Then they said pneumonia. Finally, 48 hours after we arrived at one of the foremost hospitals in the nation, with excellent insurance, a doctor noticed that my wife had come in on crutches, from a recent leg injury.

It took two days to diagnose her pulmonary embolism, at a great hospital, with great insurance, with me there as her advocate, with obvious symptoms. It's just fucking scary.
posted by MrMoonPie at 9:57 PM on March 31, 2012 [18 favorites]


It's worth noting that "drug-seeking" is often a sincere attempt to manage real pain.

Yeah, I totally don't buy the idea that there are mountains of addicts hanging out in ER's, trying to cop for free drugs. At the very most, it's going to get you a single dose of some weak-assed shit. Any addict who tries it once soon gives it up as a bad job on the basis that you can beg the price a bag of heroin faster than you can get to see and then persuade an ER doctor to prescribe anything worthwhile.

Not saying it isn't a problem per se, but in ER rooms? Not having it. Not even in Buttfuck, USA. If it wasn't worth doing in the early 70's in the UK, it's surely not going to be worth doing at the heart of the War on Drugs forty years later. It's just an excuse cowardly medical personnel give to avoid providing adequate pain relief to those who can't afford to pay for their treatment.
posted by PeterMcDermott at 11:02 PM on March 31, 2012 [3 favorites]


It's just an excuse cowardly medical personnel give to avoid providing adequate pain relief to those who can't afford to pay for their treatment.
Again, poor people have medicaid. This woman had medicaid. Payment was never an issue.
posted by delmoi at 11:16 PM on March 31, 2012


I believe she had trouble breathing after she had already been jailed for refusing to leave an ER because she was in pain and wanted treatment. She said her legs hurt too bad to walk, so the cops dragged her into the jail. She died on the floor of her jail cell, alone.

In that circumstance, I think it's safe to say she was doomed, but not by anything she herself failed to do.
Uh, right but my question was whether or not she would have lived if they'd treated her differently. When I first thought about it, it seems like proper care and compassion might not have actually saved her, but looking at the thread it seems like maybe she could have been, but maybe not.
posted by delmoi at 11:18 PM on March 31, 2012


Sigh.

Yes, the personnel of emergency departments are widely renowned for their cowardice and avarice, especially as their salaries are determined by how much money they make from their patients. The real saints of the medical profession, as we all know, are much more likely to go into the more stressful and less lucrative field of elective cosmetic surgery.

It couldn't possibly be that you don't necessarily have a handle on all aspects of modern drug culture.

delmoi, who knows? But it's not really a relevant question. She shouldn't have been arrested, so the process that resulted in that outcome is broken.

But then we knew that, really.
posted by kavasa at 11:21 PM on March 31, 2012 [5 favorites]


And if you have leg pain, even if you haven't flown lately, don't ignore it
I'm popping in to say that I once woke up with terrible leg pain, and from the knee down, it was red and swollen. I immediately hied myself off to the ER, thinking DVT, freaking out that I could die on the way there.

Turned out it was cellulitis, but it was BAD. Like, any worse and I would have been hospitalized bad.

So yeah, don't ignore leg pain ever. For any reason.

Also, avoid getting bitten by poisonous spiders. The skin never reforms correctly and I've had three bouts with bacterial infection at the site of the bite. Okay, don't treat users like criminals, don't send a cop to do a doctor's job we return you now to your regular topic
posted by PapaLobo at 11:28 PM on March 31, 2012 [1 favorite]


Also: Avoid being poor and/or a minority.
posted by steamynachos at 12:23 AM on April 1, 2012 [2 favorites]


It's horrendously absurd how resistant doctors are to prescribe real opiate painkillers. Literally 99.9% of people who are prescribed opiates use as directed and never abuse them. The remaining .01% might get addicted, but yaknow what? They'd find drugs anyway, so we should have programs where both compassionate treatment is available, as well as pure legal drugs at a reliable dosage, along with clean needles and a safe place to shoot.

The fact is that opiates are actually really good at what they do, and the vast vast majority of people know how to handle of them. The rest should be treated humanely so they don't cause trouble for the rest of us.

Why should innocent sick people have to suffer because the US government is addicted to propaganda and paranoia?
posted by Afroblanco at 12:25 AM on April 1, 2012 [6 favorites]


Oh Christ, you bet your ass drug seeking is a problem and it pisses me off to no end, precisely for this reason -- it distracts medical providers from providing actual medical care to people like this who need it. Even if this woman wasn't a drug seeker, she sure as hell was a victim of drug seeking. Jaded ER, and yes primary care and urgent care doctors work in a milieu where there is a constant onslaught of relatively young people appearing at their door with no clearly visible source for their dramatic presentations in pain.

Prescription drug abuse, and more specifically, prescription drug overdose has become such an epidemic in my community that Washington state recently passed legislation and unrolled a state wide database (based on insurance claim data) where any provider who enrolled in the program can look up all prescriptions for controlled drugs for a given patient in any statewide pharmacy. I use it for any patient I don't know who comes to see me with a pain complaint and quite honestly it's astonishing how many perfectly reasonable looking people have dozens of prescriptions all over the state. Ironically, it's the people who look like drug seekers who are generally on the level. Real hardcore prescription addicts are too slick to show up disheveled and ask for specific pills by name. Granted, I work in a clinic that caters to uninsured and Medicaid patients so my population is skewed, but I trust no one at this point. The negotiations and abuse providers took over pain med requests began to take up so much of our time and interfered with our primary mission to such an extent that our organization finally adopted and advertised a no-narc policy, as did several ERs that we feed into. Sure, if someone has cancer metastases or a broken bone, I will "overrule" the policy, but I got so sick and tired of my focus in the exam room being hijacked away from diagnosis and empathetic treatment in favor of "do I really believe this person's pain story?" that I welcomed the organization's support. When I'm really in doubt, I ask the patient for a drug test. And you know what? On at least half a dozen occasions I have had people who've gotten themselves clean and returned to establish a primary care relationship because I "was the first physician who ever said no" to them.

Yes, I totally buy into the fact that it's inhumane to let some one suffer in pain when strong opiates exist, but in practice its very hard to treat *everyone's* pain and prevent accidental overdoses, prevent pills from being sold to children in school yards, and still find the time to you know, diagnose and treat sick people. Preventing prescription drug addicts from getting their fix is actually the least problematic aspect of this phenomenon. Misdiagnosing the Anna Browns of the world is the real issue.
posted by Slarty Bartfast at 1:18 AM on April 1, 2012 [21 favorites]


I put myself through college as a EMT in a busy community-funded trauma center ER. On any given night, our beds were 1/4 - 1/3 full with non-emergent, drug-seeking homeless patients. Most of them came through triage daily, knowing that we would legally have to see them (thus giving them a few hours of warm shelter and, if they were lucky, a sack lunch with a bologna and mustard sandwich.)

On cold or rainy slow nights we took mercy on them and let them stay. On busy nights, we got them through as quickly as possible to make room for the people who actually needed help. Every long once and a while, we would push through a drug seeker thinking his/her claim was bogus, while in reality the person was in distress. One night, one of the "regulars" (as we called them) went into a-fib in our lobby and subsequently died. The triage nurse on duty didn't take his chief complaint of "chest pain" seriously, since this particular patient had a habit of "crying wolf," so to speak, and coming in with dramatic symptoms in order to be seen more quickly.

Another "regular" used to call an ambulance from the pay phone across the street as soon as he was discharged. The ambulance had to pick him up and we had to put him through the system again. He did it because he knew that we wouldn't want the resources to be wasted every time he called the ambulance. It was cheaper and more time-efficient for us to just keep him over night on a bed in a corner somewhere than it did to keep discharging him and triaging him over and over. (Ironically, a few years after I left that particular ER I heard that the guy was hit by an ambulance and killed while crossing the street in front of the hospital on his way to the very same pay phone.)

Anyone who works in any inner-city ER will tell you that this stuff happens ALL.THE.TIME. There are a lot of complex factors involved, but I think the complete lack of social support for the destitute, the drug-addicted, and the mentally ill is one of the biggest culprits.
posted by Kevtaro at 1:30 AM on April 1, 2012 [4 favorites]


Slarty Bartfast : why have you appointed yourself moral guardian for these people? Whether they're addicts or not, they need their drugs. Would you rather the addicts cop from a black market heroin dealer, where they know neither the dose or the purity? Guaranteed you'll get more ODs that way.
posted by Afroblanco at 1:34 AM on April 1, 2012 [5 favorites]


Literally 99.9% of people who are prescribed opiates use as directed and never abuse them.

Do you have a citation for this? I do not believe such data exist, and, as I mentioned, this is very much not my experience. I suspect it is highly dependent on the region and socioeconomic class of the population. Much of the data regarding the "safety" of opiates came out > ten years ago and was generated among referral populations and then extrapolated inappropriately to ER and primary care practices.
posted by Slarty Bartfast at 1:35 AM on April 1, 2012 [2 favorites]


Slarty Bartfast : why have you appointed yourself moral guardian for these people? Whether they're addicts or not, they need their drugs. Would you rather the addicts cop from a black market heroin dealer, where they know neither the dose or the purity? Guaranteed you'll get more ODs that way.

As I mentioned in my comment, I don't give a rats ass about what a drug addict chooses to do. What I care about is how this influences the way I treat my patients. If I am having a crazy over-extended day (ie every day), you bet I'm going to skip over people that I suspect are just looking for a fix in favor of people who really need a doctor, and it isn't appropriate for me to be making these snap judgements.
posted by Slarty Bartfast at 1:39 AM on April 1, 2012 [5 favorites]


Also, I hate to walk away from this discussion, but its nearly 2 am and I have to work at 7, so I'm out for now, but will be back tomorrow. Obviously, I have daily experience with this problem and have strong opinions about it.
posted by Slarty Bartfast at 1:49 AM on April 1, 2012 [2 favorites]


Do you have a citation for this?

If this conversation's still going on tomorrow, I'll get a better source, but I just pulled "The Tipping Point" from my bookshelf, and it contains the following passage :
In the 1996 Household Survey on Drug Abuse, 1.1 percent of those polled said that they had used heroin at least once. But only 18 percent of that 1.1 percent had used it in the past year, and only 9 percent had used it in the past month"
And remember, that's HEROIN they're talking about, not codeine or anything. Hell, in some countries, codeine is even available over-the-counter. The fact is, opiates are not particularly habit-forming for the vast majority of the populace; that's why they've been part of the doctor's medicine chest for so long. Most people will get vicodin for their wisdom teeth removal, their prescription will run out, and they'll just get the hell on with their lives.

What I care about is how this influences the way I treat my patients.

Heh. Yeah, one of my friends is a pharmacist, and her take on it was that she basically resented the fact that she was forced to play a part in the war on drugs. Basically, she didn't take a position on the issue, and hated the fact that her time was wasted on it. She wished that addicts would be smart enough not to use their insurance when they were drug-seeking, because if they didn't, she could fill their prescriptions and let them get the hell out of her pharmacy.

Really, what it comes down to is that drugs should be legal, addiction shouldn't be stigmatized, nobody should be forced to go to the black market because they have a sickness, and patients who are physically ill should never be denied really effective medicines that do exactly what they need to do and don't pose a threat to the vast majority of the population.
posted by Afroblanco at 1:52 AM on April 1, 2012 [3 favorites]


Obviously, it's impossible in practise to not care about whether or not people really need drugs, but why not just give drugs to drug seekers and not worry about triaging the needy from the fake?

There are a lot of complex factors involved, but I think the complete lack of social support for the destitute, the drug-addicted, and the mentally ill is one of the biggest culprits.

Lack of a proper health care system, which means a lot more pressure on emergency rooms and such as people avoid proper care until it's almost too late, combined with the war on drugs and the lack of facilities to help drug users and homeless people undsoweiter.

Even in the Netherlands though, which does (still) have those facilities doctors are trained too much to worry about drug abusers so that people who do need it for pain management are still mistrusted.
posted by MartinWisse at 1:53 AM on April 1, 2012


If we did something like the Common Ground approach to assist the homeless, had ready, reliable medical assistance for poor people (Some bill that expanded medicaid to all poor people, instead of just a certain subset of especially poor people who are also pregnant, children, or disabled might be a good start), and the previously mentioned assistance for drug addicts instead of criminalizing drug addicts (and then failing to provide them with assistance, or even decent health care while imprisoned, in addition to pricing them out of health care after release), then the emergency rooms could be clear, and doctors and nurses could, I dunno, care for people who need emergency care? The people clogging up the system aren't the problem. The system that doesn't give people anywhere else to go is the problem.

I'm going to bed.
posted by Garm at 2:03 AM on April 1, 2012


I'm in chronic pain but I'm a middle class white woman so it's okay to give me drugs.

Hook a brotha up!
posted by Brandon Blatcher at 5:25 AM on April 1, 2012 [1 favorite]


St. Louis PD, everything bad you have ever heard about them is probably true.*


*has job stripping the ones that get caught of their peace officer license.
posted by Atreides at 5:57 AM on April 1, 2012 [3 favorites]


I take opioids sparingly for shoulder pain ( a 60 pill scrip for 10mg oxycodone lasts about a year), but I thoroughly enjoy the effect and understand the attraction of narcotics - it's a complicated subject, at the very least.

But I think we've seriously conflated medical issues with criminal issues. Criminality should have fuck-all to do with what you ingest; it should only deal with anti-social behavior. If you can ingest drugs and still behave responsibly, then more power to you.

If your drug-taking becomes a problem in your life, then you have a medical problem - and should be treated as such.
posted by Benny Andajetz at 5:59 AM on April 1, 2012 [4 favorites]


SO went to a clinic recently and saw a large sign, "We do not prescribe pain medication for any reason."
posted by RobotVoodooPower at 6:14 AM on April 1, 2012


Kevtaro, thanks for your post.

One of the worst parts of our broken system is how it grinds down people who do want to help by putting them constantly in impossible positions--like the position of having to choose between a homeless person needing shelter and someone with a medical emergency needing the same bed.
posted by emjaybee at 6:18 AM on April 1, 2012 [4 favorites]


A shift to more urgent care providers to ease the burden on ERs.

Only for people with health insurance and non-serious injuries. I'm pretty sure urgent care providers aren't under the same obligation to treat anyone coming through their doors, regardless of ability to pay, that E.Rs are.

In my experience, urgent care offices are great resources for the weekend sports injury or the child running a fever after your family doc's office is closed. The caveat being that they don't treat a hell of a lot that can't be handled with a bandaid. I sliced-open the tip of my finger once and could not stop the blood flow. It was 5pm on a Saturday. I called to make sure the urgent care place was open (they were) and described my injury. They told me straight-up to go to the ER...That they did not handle such injuries. Made me wonder what constituted "urgent" in their business plan.
posted by Thorzdad at 6:54 AM on April 1, 2012 [2 favorites]


Afroblanco,

I will reemphasize what SB said upthread. It also may help for you to understand that as primary care doctors,if our treatment ever slips into the realm where it is felt to represent managing opiate addiction, we will lose our license, no questions asked.

Any reasonable primary care doctor is going to have quite a few opiate using patients. It is necessary to understand all sides of the issue and also that opiate medications prescribed in the medical setting are probably the single biggest reason that adolescents start using opiates and eventually heroin simply because of how easily available they are from their parent's medicine cabinets, and of course because they so efficiently obliterate the typical adolescent's sense of unease and angst. So while the adult brain may be more able to withstand opiod influences, the adolescent brain is a different animal. Your political views on opiate use unfortunately are not something that law enforcement, the Board of medical examiners, or the adolescent brain really have a lot of common ground with. And the accidental opiate overdose statistics are sickening. So if you are a prescriber, on any given day, doing what is "right" is not exactly straightforward.

The likely truth of the matter, I suspect, is that for most primary care doctors, we would rather take our time to treat patients' actual issues and if it comes down to it, err on the side of caution and treat pain at the risk of being tricked out of one or two opiate prescriptions. it is fairly easy to figure out who the doc shoppers are, especially now that prescriber databases are becoming more normal. Having said that, any doctor taking new patients will tell you that the odds of picking up a drug seeking patients are quite high on any day where you were seeing someone for the first time. This was not always as obvious until we could consult databases and see how many urgent cares, dentists and other mid-level providers they had seen in the last month. And yes, you may be right in that it is easier to score heroin on the street but for whatever reason that is not what we are seeing. What we do see are patients going through hundreds of Vicodin, Percocet or oxys in one or two weeks time or, perhaps more typically, turning around and selling them. Part of our obligation as part of opiate prescribing is periodic drug testing. You might be surprised by how many people who are supposed to be taking opiates on a regular basis show up with nothing in their urine, and I can assure you it is not due to rapid metabolism. So diversion is a big problem also.

I would simply encourage you to consider potential downstream consequences of more generous opiate prescribing in the community.
posted by docpops at 8:14 AM on April 1, 2012 [7 favorites]


Again, poor people have medicaid.

It seems inaccurate to say that poor people have medicaid as it's a fairly restrictive program. The poor people I've known (save one on SSI) did not have medicaid.

When I had a neurological condition that kept me destitute, homeless, and unemployable for several years, I looked into medicaid. The program requirements meant that I was ineligible - if memory serves, I would have had to be on SSI in order to receive medicaid.
posted by Radiophonic Oddity at 8:47 AM on April 1, 2012 [1 favorite]


I called to make sure the urgent care place was open (they were) and described my injury. They told me straight-up to go to the ER...That they did not handle such injuries. Made me wonder what constituted "urgent" in their business plan.

Your urgent care center is a heck of a lot more limited in scope than the one my family uses, then. Ours has no problem handling stitches, and even (very) minor surgery (my daughter had to have an ingrown toenail cut out, which they were able to handle for us no problem.)
posted by deadmessenger at 8:52 AM on April 1, 2012


I live and work with the "homeless" in Vancouver, B.C. and I have talked to countless numbers of "homeless" and/or "addicts" who have been chased out of the hospital by security, before they can even take a number for the long queue. There are "homeless" people that actually sleep outside of the hospital's, under the benches and in the bushes.
I have seen (more than once) paramedics called to respond to a semi-conscious “homeless” person (on the street and in a shelter) and walk away “cause it’s just a junkie”.
I have talked to many poor and/or street people with serious health issues (from HIV to cancers to heart conditions) who either have minimal access to health care or refuse to access health care, because of the way they have been treated.
There is a clear and obvious pecking order in our health care system, as there is in the prescription (and illegal) drug trade.
I don't blame individual health care providers, nor the hospitals. It is a systemic problem, that starts at the top.
note: I put "homeless" (and "homelessness") in quotes, as these words are quickly becoming institutionalized for representing the serious downward spiral of our housing and social service systems.
posted by what's her name at 8:57 AM on April 1, 2012 [3 favorites]


Just my anecdata as a upper-middle-class black male in SF:

I live in what is euphemistically known as the TenderNob, the sort of no-man's land between Nob Hill and the Tenderloin, the latter being a modern-day equivalent of The Wire's "Hamsterdam" minus the killings because narcotics are pragmatically a non-issue for SF law enforcement. Such are the benefits of neurochemical liberalism.

In December 2012, with virtually no risk disposition, my right wrist became septic. Turned out to be normal staph and strep gone haywire (once bacteria hit the synovial fluid of a joint, it's GAME OVER buddy: surgery or death). My PCP bifurcated her initial diagnosis: septic joint or pseudo-gout. Given no disposition to septic joint, she went with pseudo-gout.

7 hours later in the ER at Saint Francis Memorial an on-staff doc aspirated my joint (fucking ouch) and I was on Vancomycin and scheduled for surgery the next day.

I was asked by that first doc what I wanted for pain. I had no idea what I wanted, having no experience with opioids except for Codeine which gave me such weird dreams when I'd gotten my wisdoms out that I discontinued use after 48 hours. He told me I called the shots and I was in such pain I just told him to give me whatever he thought would work.

He went with morphine. Asked me how I felt. I told him, I feel OK. How was I supposed to feel? He had another does administered and asked me again. I told him I supposed it was working. He stuck my wrist and I have NEVER felt agony like that in my life. He gave me a 20-min rest and had dilaudid administered which felt much different than morphine.

Turns out I am paradoxical wrt morphine: increased heart rate and no analegesic benefit. After I was discharged I was prescribed Oxycontin and Percocet, both of which I discontinued after 48 hours in favor of marijuana because that shit just gave me fucking crazy weird dreams.

tl;dr: being black (and educated?) in SF near a well-known drug haven did not make it difficult for me to get narcotic pain killers. Other than the bifurcated diagnosis (understandable) I was pretty well taken care of (had I not gone to the ER that night, I might not be here now).

Also, there is all kinds of horror lore about St. Francis. The more affluent (educated, white, snobby) will get over to UCSF for 2-4 hour waits. My experience was a 15-minute wait with smart, cool, hip medical staff. The operating room felt like living in the 21st century though the traction equipment was a little lacking.

Apparently St. Francis is dedicated to a 20-minute wait time or less for ER. Being black in inner city SF Worked Well for Me™ and I would not be here to type this if I'd been treated as poorly Anna Brown had been.

She, we, all deserve better.

.
posted by mistersquid at 10:18 AM on April 1, 2012 [3 favorites]


I just pulled at a patient out of a hospital for hospice admission last night, the patient was literally shaking with pain, metastatic lung cancer. He was screaming and crying, a white elderly male. The hospital staff wouldn't give him anymore morphine because "we don't want to create an addiction". He was DYING and miserable and the hospital was worried about addiction...blows my mind, truly. Any time I have to work with an MD who isn't familiar with hospice, it's a nightmare. Prescribing tylenol every 6 hours for a dying woman who could only moan and cry she was in so much pain, he also told the family not to let hospice give her pain medications as that would kill her. When I stop nursing it will be because of these doctors and their complete disregard for the patients. I can take them being jerks to me but to ignore someone's pain and let them die miserably, well that's the stuff that I replay in my mind over and over...their paternalistic condescending attitude is more than annoying, it causes real harm.
posted by yodelingisfun at 11:12 AM on April 1, 2012 [13 favorites]


I would simply encourage you to consider potential downstream consequences of more generous opiate prescribing in the community.

Likewise, I would encourage you to consider whether the "potential downstream consequences of more generous opiate prescribing in the community" have something to do with drug prohibition. The fact that these drugs are illegal encourages addicts to hide their drug use, to lie to doctors and take risks to obtain drugs, to sell their drugs to others at inflated prices, and to use more dangerous drugs with a greater risk of overdose (Percocet and Vicodin contain acetaminophen, for instance). If doctors could simply prescribe opiates in order to manage opiate addiction, then the motivation for these harmful behaviors would decrease, and many patients' addictions could proceed under medical supervision.

Portugal decriminalized heroin in 2001, replacing criminal consequences with treatment programs, and the experiment was a great success -- heroin use and deaths from overdose dropped substantially, while treatment rates went up. We can do the same with prescription opiates, if we admit that addiction is a medical problem rather than a criminal one.
posted by vorfeed at 11:43 AM on April 1, 2012 [2 favorites]


Prescribing tylenol every 6 hours for a dying woman who could only moan and cry she was in so much pain, he also told the family not to let hospice give her pain medications as that would kill her. When I stop nursing it will be because of these doctors and their complete disregard for the patients. I can take them being jerks to me but to ignore someone's pain and let them die miserably, well that's the stuff that I replay in my mind over and over...their paternalistic condescending attitude is more than annoying, it causes real harm.
posted by yodelingisfun at 11:12 AM on April 1 [4 favorites +] [!]


You need to relocate or tone down the hyperbole. What you are describing is a sanctionable offense, and in twenty years of working in more than a dozen hospitals around the country this attitude has never shown itself. It's not as though I think it can't or doesn't happen, but this is a trope that shows as much of an agenda as any other. Or else you must have some pretty atrocious luck. Next time that happens to you, report the doctor.

Vorfeed, you make some good points. Perhaps in a future era addiction medicine will do just what you suggest. Right now, on any given day, we are expected to be psychologists, social workers, parents and cops in addition to practicing medicine. Getting sucked into the vortex of drug policy and potentially watching decades of expertise and training snatched away by the feds just doesn't hold the luster you might wish it did for us.
posted by docpops at 1:14 PM on April 1, 2012 [2 favorites]


The hospital staff wouldn't give him anymore morphine because "we don't want to create an addiction". He was DYING and miserable and the hospital was worried about addiction...blows my mind, truly.

Wow. That is so far outside what is ethical, it could put one's medical license at risk, certainly a hospital's JCAHO certification at risk. This is certainly not the kind of paternalism I am advocating. In fact, the brochure my clinic hands to potential drug seekers is entitled "Policies and Procedures with regard to Non-cancer Chronic Pain."

The kind of scenario that I run into every day is some variation of "Hi doc, I've had a sore back for 20 years and my last doctor was giving me 400 Percocet a month and it's been working great. I recently lost my insurance so I have to switch doctors. Also, I ran out of my medicine today." or "Doc, I am having the most excruciating migraine of my life! I'm allergic to ibuprofen, tylenol, codeine, and Vicodin and all the migraine medications. I'm going to lose my job and get evicted from my apartment if I can't get something to treat the pain today." This literally happens every single day, multiple times a day. If I err on the side of just giving people what they ask for, without verifying their story (as I have done with I was younger and more naive), then I will be prescribing for them forever and my practice will soon fill up with patients looking for nothing else besides that prescription. If I take the time to verify the story, call old doctors, drug test, not only does it take hours that I don't have, but the potential pay off of finding the rare patient who might actually benefit is so infrequent that the only logical approach, if I have any professional integrity or desire to actually help people who have illness beyond isolated pain symptoms, is to simply refuse narcotic prescriptions across the board to everyone. There's plenty of other things I can do for migraines and back pain.
posted by Slarty Bartfast at 1:23 PM on April 1, 2012 [1 favorite]


So, Slarty, suppose I come in for a chronic and serious problem with pain. And --truly--I AM allergic to codeine and all opiates (massive itching, swelling, redness of face, even inability to breathe well.) So what would your response be? Not trying to start an argument; just curious, since you cited codeine.
posted by etaoin at 1:37 PM on April 1, 2012 [1 favorite]


well sorry guys those things DID happen and happen regularly, I'd love to "tone it down" if it weren't you know, true. And where exactly am I supposed to relocate to? Pain is so under-treated everywhere in this country it's crazy. I have heard the no pain meds because we don't want to create an addict bs so many times from non-hospice docs that we address it in the hospice handbook. And I did report the doc with the tylenol but he's still out there being a jerk so what did it accomplish other than make him less likely to call in hospice in the future? I'd love to hear that all docs are treating pain appropriately and not just for the dying but it's not true. I work with some amazing doctors and am grateful for that but there are a lot of really awful people out there practicing medicine and actively harming their patients. I'm sure it wouldn't be you guys of course, all the nurses that work with you would say you are kind, compassionate and thoughtful in your decisions? And good for you buy don't try to pretend that is how it always or even usually is...
posted by yodelingisfun at 1:50 PM on April 1, 2012 [2 favorites]


And then there's this, on the topic of lack of insurance:
http://drjengunter.wordpress.com/2012/03/28/cancer-v-the-constitution/
posted by etaoin at 1:53 PM on April 1, 2012


etaoin,

More than likely you would have learned from experience to come armed with substantiating documentation like medical records and refill history. Then we would check your name against the state database. Then check the local hospital records to see what those showed. Then it's conceivable we could give you a very limited rx until you were established with a chronic pain management clinic. Oregon statutes require a consultation with a secondary specialist in the area of the patient's pathology, i.e. spine/ortho, migraine/neurology, etc. So that's one general answer, and of course there are may variables, but legitimate long-term opiate users are pretty easy to manage and sort out from the start, for the very reasons that you or I would not show up at the airline counter without ID or a passport and demand a flight to Greece. That is to say, they exude a normalcy and sensibility that exactly opposes the sort of cloying characterologic ooze coming off your more typical drug seeker. Of course, as SB stated, all this takes up epic amounts of time as well as being contradictory to our stated mission as doctors (i.e not basically mistrusting our patients), so unless you are really in a clinical setting where you may be taking on a patient for the long term, it's often the case that you just simply say away from any prescribing at all.
posted by docpops at 2:02 PM on April 1, 2012


Psst, Medicaid is pretty terrible especially in certain states and Medicaid patients (aka "indigent patients") are treated much differently, full stop. It's managed at the state level and is known to reimburse very poorly, and providers typically can avoid Medicaid patients explicitly unless they are funded by government or work in hospitals with emergency rooms and happen to see a Medicaid patient there.

As others mentioned it's hard to get good continuity of care / primary care / non-half-assed care with Medicaid (in its defense, the emphasis on infant/child care seems pretty good, but I'm only speaking from experience in Colorado) and specialty care...good luck with that. I've seen a front desk receptionist at a primary care practice recoil in horror at the concept a patient with Medicaid somehow getting through their scheduling process. "MediCAID? No, we don't take that, they should have not made an appointment for you."

Many places flat-out refuse it unless you manage to end up in the emergency room in which case you can follow up with specialists that treated you in the ER who wouldn't otherwise touch you with a ten foot pole. And healthcare providers know that while Medicaid "pays claims," it pays dick compared to anything else. I wish it were not true, but based on my experience working for a Medicaid HMO at one point and now working for a specialty practice...the type of insurance you have (or lack thereof) is quite often a factor in your access to care, and once you sneak into the system, it factors into what is supposed to be medical decision making (as in, deciding on a treatment plan from a purely medical patient care Hippocratic standpoint).
posted by aydeejones at 2:19 PM on April 1, 2012 [1 favorite]


BTW, in Colorado at least, Medicaid eligibility is determined on a month-by-month basis and it seems that patients seem to occasionally somehow "screw up" and become ineligible inadvertently (I don't know the details on how this happens), getting saddled with huge bills. It's a bummer to be sure.

I have plenty of horror stories from the Medicaid HMO that I worked for (which managed to eventually lose its Medicaid contract and slowly disintegrated into nothingness). For one, they had two medical directors (aka out of touch doctors who effectively form a "death panel" at their worst) who couldn't possibly keep up on all of the current treatment methodologies, deciding whether to authorize cancer treatments that might be interpreted as "experimental" because the specific form of cancer is so unique and rare, possibly even one of a kind. Suffice it to say I've heard decisions that nurses in "Utilization Management" (aka nurses working for the dark decide deciding how long someone realllly needs to be in a hospital bed) were not very happy about and communicated to me over a beer in tears. It sucks.
posted by aydeejones at 2:31 PM on April 1, 2012


"dark decide" = "dark side"

"so unique and rare" should be just "rare" :)
posted by aydeejones at 2:34 PM on April 1, 2012


Having worked in urgent care and emergency settings (in Canada), I can 2nd what docpops and SB are saying. I truly resent the ass-covering mentality of the "no narcotics Rx'd here" signs that so many walk-in clinics use, but spend any time working in those settings and you will encounter scads and scads of drug-seeking behaviour. It then becomes my job - as someone who does not and never will adopt a "no narcotics" philosophy - to try to establish the legitimacy of the patient's claims, a very time-intensive activity.

As docpops said, no one in health care likes to be put in the position of mistrusting a patient. But here is how I think about it: every time I Rx an opiate (or, for that matter, a benzo: addictive, frequently misused, and often diverted to the street), I am responsible for where that drug ends up. Being sold on the street? "Stolen" by a relative/friend/partner (in scare quotes because the theft is often part of an arrangement)? Used in a transaction to obtain other drugs? I let that drug out to be used that way. I am responsible. I agree wholeheartedly that the drug policy in North America is a pile of horseshit and could stand to be scrapped altogether, but that doesn't mean I'm ok using my Rx'ing privileges to support non-medical use of narcotics. I'm a physician, not a bartender.

Here is a useful stat for this discussion: diverted opiods (ie, obtained without a Rx) are now third behind alcohol and weed as a recreational drug used (or at least tried) by adolescents in Ontario. Cite. This is a huge shift facilitated in large part by the liberalization of narcotic Rx'ing in the past 15 years. Drug experimentation, a key point in many adolescents' coming of age, has undergone a huge paradigm shift entirely as a result of physicians and pharmaceutical companies.

Rx'in privileges are just that: privileges. I do not take lightly the responsibility or the challenge of managing a patient's pain effectively and respectfully while avoiding adding to the fucked up illicit drug use situation by letting narcotics out into the street. Yes, the drug policy needs to be changed, but that's not my role in the system.
posted by thelaze at 3:12 PM on April 1, 2012 [6 favorites]


I'm really excited that there are doctors here sharing their experiences.

Here is a good discussion from ER residents and attendings about potentially drug-seeking patients.
posted by the young rope-rider at 3:22 PM on April 1, 2012


Vorfeed, you make some good points. Perhaps in a future era addiction medicine will do just what you suggest. Right now, on any given day, we are expected to be psychologists, social workers, parents and cops in addition to practicing medicine. Getting sucked into the vortex of drug policy and potentially watching decades of expertise and training snatched away by the feds just doesn't hold the luster you might wish it did for us.

There are ways to work for drug policy reform without risking your license and without going public at all. I don't expect doctors to start passing out oxycodone like candy just because I think it ought to be legal -- for one thing, if it isn't legal then you'd be playing into the problems created by the black market -- but if we ever want the situation to improve then we need to be fighting, and doctors might make powerful allies...
posted by vorfeed at 5:44 PM on April 1, 2012 [1 favorite]


The kind of scenario that I run into every day is some variation of "Hi doc, I've had a sore back for 20 years and my last doctor was giving me 400 Percocet a month and it's been working great. I recently lost my insurance so I have to switch doctors. Also, I ran out of my medicine today."

On my end, as a patient with no insurance and no current primary care provider, this has made me terrified to complain about pain, for fear that I will be seen as a drug-seeker, and thus not receive treatment from my main, genuine complaint. Even when I have ridiculous, concrete, fairly gross outward symptoms, and there's a little sign on the wall about how pain is an important diagnostic tool.

Also, if we switch over to urgent care instead of the ER - are urgent cares obliged to see you if you don't have insurance? I always thought they were not.

Anecdata: Urgent care centers have had no problem taking me without insurance, and have even given me some financial consideration, discounting everything from blood tests, to a chest x-ray, to a biopsy. That said, while I don't have health insurance, I do have a credit card, which I'm usually asked to present well before I'm seen.
posted by evidenceofabsence at 9:46 PM on April 1, 2012 [1 favorite]


Oh Christ, you bet your ass drug seeking is a problem and it pisses me off to no end

I'm not saying that it's not a problem -- I'm saying that providers overstate the extent to which it's a problem in ER's. From the addict's point of view, it's a pain in the arse. They'll wait hours and hours, and end up face to face with somebody like you, who is pre-programmed not to prescribe to them.

How many times do you suppose they have to come up against people like you before they decide it's a waste of time and effort? I'm guessing once.

I put myself through college as a EMT in a busy community-funded trauma center ER. On any given night, our beds were 1/4 - 1/3 full with non-emergent, drug-seeking homeless patients.

I think this is a seperate issue. I'm sure your inner city ER's are full of inadequate people who are homeless, have serious psychiatric issues and co-morbidity with drug dependence. On the (rare) occasions when ER's treat these people rather than casting them back out into the street, I'm pretty sure they'll also squeal for a dilaudid or a valium -- not expecting to get them, but because -- if you don't ask, you don't get.

However, that's not how this issue is painted, which is as a bunch of devious, well-organised addicts who repeatedly hit ER after ER in the expectation that they're going to come away with sackloads of Oxycontin. If you talk to any active addict, they'll happily tell you that going into an ER in the hope of blagging a high potency opiate is a waste of time and energy and you're better off deploying those resources elsewhere.

Which isn't to say that those addicts who show up in your ER with genuine pain issues aren't going to ask for them. But I'm not sure why they should be any less entitled to adequate pain relief than anybody else is.
posted by PeterMcDermott at 12:02 PM on April 2, 2012


Wow. This is fascinating. I'm only a little aware of this "drug seeking" thing. But I suffer from all kinds of pains because I'm over 50 and have messed up legs, which only became obvious when I tried to undo decades of sedentary behavior. But I've been feeling I'm not getting very good care, and now I wonder if the doc thinks I'm after drugs. That's almost funny, since I've never enjoyed pain killers, and don't expect much of them for killing pain, either.
posted by Goofyy at 10:39 PM on April 2, 2012


Peter, I think part of the problem with that idea is that addicts aren't all rational. Breaking into houses to get money to buy drugs also isn't a very good idea and not likely to work out well on the cost-benefit analysis, but people do it. Not to say it's necessarily a majority of people who even have problems with opiates, but it doesn't take that many individuals to be a burden on an overworked ER. It's not the well-organized, it's the desperate, who don't have better options. (As to devious, that varies more, I suspect. See also Jason Mewes' ambulance trip for a fake back injury when he couldn't score in LA.)

But obviously there are people who really need pain management--and more than that, I was trying to stress as a part of this, there are a lot of people who complain of "pain" who have underlying problems that are serious and need more time and energy than can be dedicated when the ER staff are so overworked.

I don't think urgent cares have the same obligations that ERs do, but the thing is, a lot of people *with* insurance also end up in the ER for things that are not exactly emergencies but are a bigger deal than should need to wait for the GP's next free appointment. If we could get those people out of the ER (and hopefully get more people insured), I think that would leave more space to deal with drug-seekers in a way that doesn't just shove them right back out the door to go to the next place, and much more time to diagnose problems for people who're in true distress.
posted by gracedissolved at 12:46 AM on April 3, 2012


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