Even for seasoned health care workers, it can be unnerving to hear "emergency in the parking lot" over the loudspeaker. There, we found an 18-year-old man lying lifeless on the asphalt and not breathing. Before I could utter the words, an astute nurse immediately ordered that the patient be given Naloxone as she correctly recognized that this patient was suffering from an opioid overdose. Soon, the patient began to breathe spontaneously, effectively coming back to life.
This story could be used to celebrate the marvels of medicine and the skill of our health care workforce. However, this story does not have a happy ending.
Shortly after waking from his opioid-induced coma and realizing where he was, the man literally ran out of the emergency department. While I do not know for certain what prompted him to abruptly leave against medical advice, I have a suspicion. He admitted that he did not have insurance and did not want his parents to have to cover the cost of the visit; he could not qualify under his parents' plan because he was not in enrolled in school and had moved out of his parents' home.
This unfortunate situation is a common occurrence where I work in rural Maryland, and it is a shameful reminder of the inadequacy of current efforts to reform our country's system of health care. Health insurance that is unaffordable does little to address access to care and does nothing to address the skyrocketing price of prescription medications. The price of Naloxone (the medication that saved my patient's life) has increased by 500 percent over the past two years. Fortunately for residents in Maryland, Vermont and California, legislators in those states passed laws to address prescription medication price increases. However, a federal approach is necessary to ensure all Americans can afford life-saving medications.
Even as a pediatrician, I share some of the blame for the drug abuse epidemic that is now the leading cause of death for people under 50 years old. A significant percentage of those who are now addicted to opioids obtained their first dose from a physician. This is a function of how we are trained. I recently completed my residency training in pediatrics here in Baltimore, where I was often taught — erroneously — that children's pain is undermanaged. To combat this misinformation, Massachusetts now mandates that all physicians applying for or renewing a medical license must complete at least three hours of training on evidence-based opioid prescribing practices.
Hospitals trying to increase their patient satisfaction scores are also partly to blame. That a patient's pain level is included as a vital sign (which traditionally includes temperature, pulse, blood pressure, respiratory rate and blood oxygenation) implies that it must be expeditiously addressed and managed. As a physician, I am instructed to treat a patient's pain within a certain time period. Such metrics can set up perverse incentives to over treat certain types of pain. These criteria should be re-examined in light of the current epidemic.
I and my physician colleagues should do a better job of managing expectations of the level of pain that a patient may have given their specific medical condition. We can also give patients and families a variety of options. This could include initially prescribing non-narcotic pain medications and, if pain is still not optimally managed, then consider prescribing a narcotic. Massachusetts has passed legislation limiting the number of days that opioids can be prescribed in some instances. Maryland tried to pass similar legislation.
Although my 18-year-old patient lived through his most recent trip to the emergency department, there is no guarantee that he will be as fortunate the next time. Prescribing opioids responsibly could at least help ensure that there are fewer people in his position.
David Myles is a pediatrician, fellow of the American Academy of Pediatrics (AAP) and a member of AAP's Committee on State Government Affairs; his email is email@example.com.