In a prior column I described the mounting problem of prescription drug abuse and its repercussions throughout society and in particular the impact on how emergency medicine is practiced in most ERs. But what can be done about it? Like most complex issues, identifying the problem is the easy part; what to do to fix it brings out the “devil in the details.”

In 1986 Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) that had many provisions. One of which was the requirement that emergency rooms see and treat all persons without regard to financial status, economic status, social status, past history of drug abuse, etc. Virtually anyone can present to an ER and, if willing to wait long enough, will be seen and treated for any complaint whether emergency or not. Drug abusers know this and frequent emergency departments regularly. They know that they must be seen and thus have the opportunity to demand their drug of choice and intimidate physicians and staff until they get what they want. Often there are critically ill patients to be cared for and the harried physician finds it expedient to simply give in to the demands so that they can get back to caring for truly needy patients.

Hospital administrators unwittingly contribute to the problem. They are usually well-trained and savvy businessmen, but without a clear understanding of the uniqueness of medical care. They are very sensitive to patient complaints and especially threats of complaints to the regulating agencies. Such complaints can bring down the full-force of the government and can cost the hospital hundreds of thousands of dollars to defend. Drug seekers also know this, and are the first to complain if they don’t get what they want. This situation leads to pressure on physicians from above to do whatever it takes to keep everyone happy. Unlike other kinds of business, in medicine the customer is not always right! The ethics of our profession demands that we do the right thing for patients, but patients don’t always agree with our opinion of what is right. OxyContin® isn’t the best drug to treat a sprained ankle in most cases, but if that is what the patient wants we risk having to answer a complaint if he doesn’t get it.

The effect of all this is physicians prescribe abusable drugs at a very high rate even when we believe ibuprofen would be adequate.

In my early days of practice if a patient presented wanting controlled substances repeatedly and unreasonably I could simply tell them to go away and that they would not be getting any more drugs from me. Today, that approach would be illegal and would surely bring on the regulators who are all too eager to assume the worst of health care professionals.

There are many social factors in the prescription drug problem that I have not addressed here, but if we were allowed the medical profession could do their part by refusing drugs to those who have demonstrated that they are abusers. This would mean sharing information with other ERs and health professionals (now illegal under HIPAA laws). Additionally, I would like to see better enforcement of current laws regarding drug diversion and doctor shopping, and stepped up prosecution of doctors who make a very good living selling prescriptions for whatever drugs an abuser requests. Some of these doctors call themselves “pain specialists,” but they are the moral equivalent of the corner drug dealer.

Dr. Hatcher is a practicing physician and university professor living in Indianapolis, Indiana.

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