Quagmire: To Laugh or Cry

Jacob wrestling the angel (from which he acquired back pain)

During the last two years I have treated a young woman who personifies my perception of the challenges of America (and our health care system).  She has limited educational and economical opportunities, landed in a threatening marriage, was injured in a car accident, and is overweight and unhealthy, now with severe pain and a resultant narcotic dependence (doctor prescribed).  Her MRI scans demonstrated significant disc herniations in both her neck and back with severe nerve compression, etc.

Ancient treatment for back pain

Despite all the factors mitigating against success, I offered her surgery hoping it might help lift her up and allow her to move forward with her still young life (she was just 29).  I was thrilled at her post-op visit after her second surgery to see a better dressed, slimmer, and much more animated woman greeting me.  She had thrown out her abusive husband, returned to work part time and lost 15 pounds.  Her progress was outstanding and encouraging.
Fast forward 12 months-she is back and the sight she cuts is not nice.  Now her skin is gray and droopy-an obvious reflection of poor nutrition, her weight has rebounded plus some, her narcotic use is higher than ever, and her back pain has returned. And then she relates a particularly distressing tale, motivated, I think, by her own guilt.
After her second surgery, her insurance company sent my professional fees to her (this is a local practice when the doctor does not work within the insurance network) a check of several thousands of dollars for this complex spine procedure.  She tells me she deposited the check in her bank with plans (when it cleared) to write me a check to cover her fiduciary responsibility.  However, because of unrelated financial problems, the money was "seized" or "frozen" by some creditor and taken to pay off some other debt she owed.
I admit, I am gravely disappointed-nothing worked the way it should.  This woman has potential that I fear she will never realize.  I have performed surgery that I have not received compensation for because of the perverse insurance system we live under. A quagmire and a failure-I feel a part but also feel helpless as an individual in a complex system. I fear that until we address the totality of these types of issues, our health care system will continue to groan and fail for many similar individuals.

My Kids Told Me

With their usual candor, my two college-age kids have told me that the current rage on campus (beyond the usual alcohol and marijuana) are...various prescription drugs.  Everything from adderall for academic performance enhancement to percocet for Saturday night buzz-college students across the country are transforming legal medicines into recreational tools.  As a physician who writes many prescriptions for narcotic pain medications (there is little a painful as a multi-level spinal fusion), I have gained a new appreciation for the potential impact I may be having on our young adults.  

The way I see it, these drugs are getting to campuses in one of a few ways:

1. Kids are stealing them directly from their parent's medicine cabinets (for use or sale),
2. Patients are selling all or a portion of the Rx that doctors write them,
3. Doctors are getting paid for Rx writing mills (more than one physician in my community has been caught red handed in this scenario), or
4. Drugs are being stolen from pharmacies or similar.

Some of you may be saying, so what? In every generation, the youth will find a way-in my college years the drugs were quaaludes and cocaine, for a while ecstasy and meth were all the rage (and still are in some places), why should the current fad prick up my skin? I guess as a physician who is committed to healing, I loath the idea that I may be contributing to addiction and ill-health.  Is there anything we, as conscientious physicians and/or parents can do?  I would recommend the following:

1. Mandatory directed education on narcotics, particularly on setting strong office policies that help prevent abuse,
2. Public awareness campaign regarding protecting medicine cabinets,
3. Accelerate reporting to physicians of patients receiving prescriptions from multiple physicians,
4. Provide greater incentive for physicians services related to drug detox/withdrawal (currently no specialty takes this on as their responsibility outside the extremes of inpatient drug addition facilities).

If you have other ideas, I would love to hear them-it is time we as physicians gain an increased awareness of how we may be inadvertently contributing to "unhealth", not part of our Hippocratic Oath.