We are still all in it together, at least as best as I can tell from recent experiences.  In the past few weeks I have had several deja vu encounters, occurring in separate emergency departments in different states.  Most recently, I was coming on shift and taking sign out from a colleague who informed me of a challenging discussion. A patient was insistent that he was to get his narcotic prescription refilled, that the original prescriber was not reachable, offering no means for the patient to get in touch, and of course, to just go to the emergency department (ED). Despite the patient acknowledging that he had not taken the medication as prescribed and that the sixty tablet prescription was to last another week or so, but was already metabolized, he remained steadfast, that he must get a refill immediately.  The patient was not in extreme pain nor compromised to any concern whereby refilling the prescription most definitely was not a consideration. 

I accepted this to be the case in listening to my colleague.  Less than fifteen minutes after the patient had left the ED, I received a call from the same patient.  He was irate, requesting to speak to the provider or a supervisor regarding the way in which he had been spoken to, with no consideration to refill the prescription and no opportunity to get in touch with the provider who wrote the original prescription, and therefore what was he going to do.  He felt disrespected, demonized, and accused of essentially being a criminal.  He acknowledged having been on the road for work, taking too much of the medication and now nothing left for the weekend.  How could this be happening to him?  It was helpful to hear the patient out along with how humiliated he was from the interaction in the ED.

I offered my understanding as to how the patient could be frustrated and his sense of being offended.  However, I supported my colleague’s position in not filling the prescription and told him that neither I nor the ED supervising physician would write a new narcotic prescription.  The patient actually was somewhat more accepting of the circumstances, and appreciated that emergency departments and providers who don’t have any ongoing relationships are continuously faced with similar circumstances.  It became clearer that the discussion in the department had been very challenging for both individuals, as they frequently are. Unfortunately, patients are left hanging, with perceptions of being accused of wrongdoing and without any reasonable or timely alternatives being offered to them.

Another colleague texted me the following day sharing his tumult regarding providers managing patients with chronic pain, that they should be required to make themselves or their practices available 24/7 to emergency departments and urgicare centers, and, to further detail, that if they are paged, a return call be made within 30 minutes or other reasonable timeframe.  The norm, however, is that there are no return calls, regardless of the time of day, or day of the week, when it is known that the inquiry concerns pain medication. 

As the focus draws in toward more restrictive prescribing practices, governance and hopefully more timely surveillance capabilities from the Prescription Drug Monitoring Program, consideration to implement equally directed and stringent requirements for those who manage chronic pain should be integrated.  There would be value added from mandating timely, conscientious and professional service agreements requisite for licensure renewal.  This could prove to be highly effective in many ways.

Lukas Kolm, MD MPH, FACEP

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