The Epidemic of Prescription Drug Abuse

Recently, I learned of some shocking statistics:
* Every year, pharmacies dispense 257 million prescriptions for opioid painkillers — one for every adult American.
* While the U.S. makes up less than 5 percent of the world's population, Americans consume 80 percent of its total opiate supply.
* 1/3 of people who used illicit drugs for the first time start by using a prescription drug.
* Prescription narcotics kill 6 times more people per year than heroin.

As an emergency physician, I prescribe narcotic drugs for pain every day. I began to wonder how complicit doctors are in furthering this epidemic of prescription drug abuse.

My recent article in NPR explores this struggle, between relieving people's pain, and possibly fueling this worsening epidemic.

When a Prescription for Pain Becomes a Gateway to Addiction

Please read, and comment! I'd love to hear your thoughts.

Goldilocks Medical Care: Not Too Little, Not Too Much….

In my last two blog posts, I discussed the harms of a new epidemic: too much medical care. We also don’t want the opposite, of enough care care. In fact, much of the driving force leading to overdiagnosis and overtreatment is this fear of rationing.

So what can you do to ensure that you obtain just the right amount of care?

It isn’t easy—if it were, if there an algorithm that would give us the answer, then we wouldn’t have the Goldilocks problem (“Is it too little? Too much?”).

Here are 5 suggestions that may help:

First and foremost, work in partnership with your doctor. The most critical key to getting good medial care is a trusting relationship between you and your doctor. This is not to say never question your doctor; but rather, develop a relationship of mutual respect such that you are the expert when it comes to your body, and the doctor is the expert when it comes to medicine.

Second, make sure your doctor listens. Study after study shows that the patient history will reveal the diagnosis in 80% of the cases, without the need for any tests or further interventions. If your doctor orders tests instead of listening to your story, that leads to unnecessary testing—and potential misdiagnoses. Prevent this by telling a good story, and making sure it’s heard.

Third, ask about your diagnosis. Understanding what you have is key to figuring out what should follow. Before you get any tests done, ask your doctor what he thinks you might have. This gives you some idea of what tests may be necessary, and also focuses your doctor to remember the important tests and have a justification for tests ordered.

Fourth, ask about every test done. Every single test has risks, so make sure you understand why each test is done. Ask about the risks. Ask about how it would change management: what happens if it’s negative? What happens if it’s positive? And, importantly—what happens if nothing is done at all? This helps you gauge how emergent (and also how necessary) a particular test is at this point in time.

Fifth, do your own research. This is particularly true when it comes to treatments. Look on the Internet and ask your friends and family. Be aware that not all information is equally credible, but at least this helps you formulate questions to ask your doctor. It might also help to look up your doctor and see if she has conflicts of interest that you may not be aware of: information about drug company affiliations, for example, can be found online. Write down questions, and ask them.

None of these suggestions are foolproof. These five steps can help begin the process for you and your doctor to work together to identify the right tests and treatments for you. If you have other thoughts or ideas that work, please write your comments below.

Guest Post: Lessons Learned In Caregiving

This is a special guest post from contributor Marcela De Vivo. 

One month ago, my son had major hip surgery at a major children’s hospital in southern California. I was so pleased when he came out of surgery without any complications.  “The worst is over,” I thought.

Little did I know that the worst was about to begin.

The day after his surgery, I noticed Nathan’s vital signs were erratic. He looked a little bit too pale and sluggish. I mentioned my observations to his nurse, who called the doctor. I requested for them to draw blood and look at his numbers. The doctor did not listen. No blood was drawn, and my son was left alone to continue his “recovery”.

The following day, Nathan wouldn’t wake up. Again, I told the doctors my concern and asked for blood work, but was once again ignored. As the day continued, my son became more and more pale. His heart rate was consistently elevated, and his respiratory rate became lower and lower. Then, it happened—his oxygen saturation dropped below 70 and he turned blue. Doctors rushed in and finally they realized that something was seriously wrong. 

This time, they drew his blood. Sure enough, the results showed that he was severely anemic. He had lost a lot of blood during surgery and needed a transfusion. Fortunately he recovered and no major damage resulted. 

This experience highlights a lesson I learned long ago as a mother of a severely disabled child: advocacy is KEY. This is just one of many lessons I’ve had the opportunity to learn. I’ve learned to find ways to help my son engage with his environment, to allow him to participate with other children his age, and to speak up for him against a school district that thinks him “unteachable.” 

I’ve learned, too, that your role as a caregiver is fundamental in the physical and emotional well being of the person you are caring for. Learning to be a better caregiver can help reduce the inherent stress that comes from so great of a responsibility. A good caregiver cares about the dignity, welfare and feelings of the recipient of the care.

Here a few ideas I’d like to share with you that you can improve your experience as a caregiver, as well as the experience of the person you are caring for: 

Patient Care

Do treat your patient/loved one with respect and dignity. Although your patient/loved one may revert to childlike behavior, he/she always needs to be treated as an adult. It could be demeaning to them to be treated as somehow lesser as a result of symptoms from the illness. Treat them as you would want to be treated yourself if you were receiving the care.

 

Don't assume that the care-receiver has nothing to contribute. Again, always treat your loved one with respect. He or she may be disabled in some ways, but that is not to say that they are useless and helpless as well. Even if they are not able to do much for themselves, give them every opportunity to cooperate in their own self-care. My son is unable to speak, but is able to answer yes by blinking and no by shaking this head. Through this rudimentary method of communication, we give him as many choices as possible: do you want this shirt or that shirt? Do you want to draw with this color? Watch that movie? This simple communication technique gives him control over his environment and the opportunity to engage with us.

Do engage in physical contact. Many of the ill, infirm or elderly who need care experience less and less human contact, especially if the condition continues for a long period of time. A hug, pat on the shoulder or light touch on the arm can improve the patient/family member’s mood and outlook.

Don’t exclude the patient during conversations. Even if the primary decisions are not made by the patient, direct questions and comments should be directed to all people in the room, including the patient/family member. Don’t act like they’re invisible, especially when discussing their care. Let the patient know that they are still important and that their attention and input matter. 

Do use verbal and visual cues. Miscommunication can be result of your patient or family member being unable to hear or see you. By using both verbal and visual cues, you decrease the chance of misunderstandings. 

Do stay organized. You will reduce a lot of stress by keeping track of all the little details required to care for your parent or patient. Make sure you have a master contact list of doctors, family members, apartment managers, neighbors, etc. whose assistance you may need. Keep track of all medications and timing of medications on a calendar or spreadsheet.  

Self care 
All too often, caregivers forget to take time to nurture themselves and find the support that they need. By taking care of themselves, caregivers improve their ability to help others. 

Do reach out for help. It is also important that you have support as a caregiver as well. If you find yourself floundering emotionally or physically from the responsibility of caring for someone else, reach out to friends, family, or find a support group. Ask family and friends to help out with the care—or with the mundane everyday tasks that you may have let slide, like household chores, grocery shopping, car maintenance, etc. Hire help if you need it. 

Don't forego sleep. It’s easy to sacrifice sleep when under duress; however, sleep deprivation has serious consequences. You will be less able to solve problems and concentrate, which can make you more impatient and cross—all of which leads to poor quality caregiving. You will be a much better caregiver when well-rested. 

Do practice coping skills. Avoid additional stressors when possible and try to maintain your self-composure while under pressure (being well-rested helps you resist giving in to your temper). Consider meditation or yoga to improve your ability to cope with stress. 

Don't compare yourself to others. Every situation is different; every relationship is different. Do the best you can for your loved one by treating him or her with dignity and respect and meeting all of his or her needs. Comparing yourself to others will only increase your stress and anxiety.

I hope these tips will help improve the quality of your caregiving and the quality of your experience as a caregiver. Taking care of yourself is a must, especially in the face of so much responsibility. And remember that you must be your own—and your loved one’s—best advocate.

Marcela De Vivo is a freelance writer from Los Angeles whose writing covers several various topics, including marketing, healthcare, technology and more. As a caregiver herself, she understands how stressful it can be and incorporates meditation and yoga to manage that stress. You can read more about her journey with her son at www.prayfornathan.org.

6 Tips For Getting Your Doctor to Listen to You

Have you ever gone to the doctor and felt like he wasn't listening to you? Have you tried to tell your story, only to have him interrupt with a checklist of questions: do you have chest pain, shortness of breath, fevers, cough, and so forth? Have you ever felt ignored, and left thinking that your doctor never understood why came to him in the first place?

The New Year is the time to make changes in your health. If you feel dissatisfied or frustrated by your care, now is the time to figure out how to get better care.

Studies show that 80% of diagnoses can be made based on your history alone. Yet, doctors these days spend less and less time listening. “Cookbook medicine” is prevalent, with doctors resorting to checklists of yes/no questions rather than really listening to what’s going on with you. You have to make sure that your concerns are addressed—and even before that, to make sure your story is heard. Here are 6 tips for getting your doctor to listen to you:

Tip #1: Answer the doctor’s pressing questions first. Many doctors are so accustomed to relying on a checklist of questions that they have to get these answers before they move on. Help them out and answer these questions. If the doctor want you to describe the location of your chest pain, describe it (“it’s in the middle of my chest, right here”). If she want to know what you took to make it better, tell them (“I took an aspirin. It didn’t help”).

Tip #2: Attach a narrative response at the end of these close-ended questions. If your doctor persists on asking close-ended questions, add a narrative response at the end that may not so easily fit into a yes/no answer (“it’s in the middle of my chest, right here, and it started after I really pushed myself in swimming tonight”). Pretend that you are being asked “how” or “why” instead of “yes/no”, and add your own response. Look to make sure your doctor registers this answer—does he ask you more questions to follow-up on what you said, for example?

Tip #3: Ask your own questions. If you don’t understand why a particular question is relevant to your situation, ask about it. You may be surprised to find that the doctor herself isn’t sure and is only asking the question out of habit. On the other hand, you may find out that issues you wouldn’t have thought were related might actually be very important to discuss.

Tip #4: Interrupt when interrupted. If your doctor cuts you off when you try to explain your full answer, free to interrupt. Pretend you’re having a conversation, even when it feels like you’re being interrogated. For example, if you’re asked “when did headache start,” rather than responding “10am,” go ahead and tell your story of how the pain started: “I woke up this morning and I was fine, then I started walking to work and the pain came on suddenly like a lightening bolt striking me.” This is not a new tactic; lawyers will often coach clients in advance to answer yes/no questions with a narrative so that answers can’t be taken out of context. Interrupting is a way to ensure that your entire answer is heard, not just the part that the doctor thinks he wants to hear.

Tip #5: Focus on your concerns. If you get the sense that your concerns are being brushed over, interject, “Excuse me, doctor, I have tried to answer all your questions, but I am still not certain my concerns have been addressed. Can you please help me understand why it is that I have been feeling fatigued and short of breath for the last two weeks?” and so on. You can take charge of the conversation at that point. It’s your body and your duty to advocate for yourself if you don’t feel like your story has been understood and your concerns have been addressed.

Tip #6: Make sure you are courteous and respectful to your doctor. Your doctor is a professional, and is probably trying her best to help you. Your story has to be heard and your concerns addressed, but make sure you present your points in a respectful manner. This will ensure that a solid doctor-patient relationship is present, and is critical to the partnership you need to establish. 

You may be dissatisfied and frustrated by your medical care, but you can take control of your health care and transform your health today. I discuss more in my book, When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests. Try these tips on your next doctor’s visit, and build your partnership for better care.

Some Advice on Partnering With Your Doctor

My last post was about Lisa Nash, a breast cancer patient who found out six months after her tumor removal surgery that she had metal placed in her breast without her knowledge or consent. Lisa is an extremely articulate woman who, in addition to being a software specialist and the mother of two daughters, has training in counseling and patient advocacy. If Lisa had difficulties getting her doctor to listen, what hope is there for the rest of us?

The bad news is that we may not be able to eliminate every negative experience. The good news it that there are some practical things you can do at your next doctor's visit to advocate for better care. Here are five:

1) Ask questions. Always start by asking for your diagnosis. What is it that you have? If your doctor can't tell you a diagnosis, what is it that you're treating?

2) Know what questions to ask. Do your research. There are many websites for your condition or your symptoms. Not every website is going to present accurate information, but looking through them will help you build your knowledge base and help you formulate questions.

3) Don't be afraid to challenge your doctor. If there is something you don't understand, ask about it. If there is something you don't agree with, speak up. Be respectful, but also remember that it is your body, and your doctor is there to help you.

4) Know the plan and ask about alternatives. The benefits and risks should be clearly explained to you, along with alternatives to the treatment plan. Informed consent means that you need to understand exactly what is happening. The doctor is busy, but this is your body and your health at stake.

5) Insist on being a partner in your care, every step of the way. You doctor will have more medical expertise than you, but you are the expert about your body.

I will continue to write articles about your stories and offer advice for you. Some more tips are on our website. As always, I welcome your feedback and comments on this blog post.