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LOOK! Another great idea from stupid people!

I have a new expression, “Another great idea from stupid* people”. Why? Because of all the idiotologies [sic] in healthcare. And here is yet “another great idea from stupid people”—at the healthcare conference I attended last, yes, the one where no one paid attention to the book, attendees were offered “new guidelines for prescribing pain medications”. Interestingly, those passing out the documents mentioned the documents were “hot off the press”. Which they were since it was the state board passing them out, documents no one else had access to and at a conference they organized. However, I do not believe the organizers were just saying that the pages were literally “hot off the press” but instead were boasting that the policy was the first of its kind in the nation. Whether it was or not the first of its kind in the nation I have no idea but for the sake of arguing lets say it was. Whoopee! Because, even if it was the first of its kind it is nothing but more of the same, healthcare’s pussyfoot culture of accommodating.

(*The use  of stupid not used towards individuals because it would be disrespectful and I lose credibility but instead used as a marketing high-impact attention getting word.)

As the policy was being handed out at the conference I chose to pass. Why? Because I am sure of my prescribing habits and that does NOT include bowing to exaggerated unrealistic emotional expectations that being the catalyst for such “another great idea from stupid people”. Regardless that narcotic prescribing has anything to do with poor customer satisfaction scores and something I have stated over and over but others are not convinced.

So, imagine how surprised I was to learn that some in California have proposed the same “great ideas from stupid people”. Just kidding, I wasn’t surprised. Why not surprised? Because, although I know I sound like a broken record despite that and the irony that critics point that out it keeps happening. Nonetheless, here is no more than the same Old CRAP(!) and an article that needs reading before continuing.

This time it is California who wants to shine with “another great idea from stupid people”. As mentioned, I am certain the catalyst for Arizona’s policy is the customer experience and I am sure it is the same for California. Both states suggesting it is healthcare workers who need to be policed with regard to prescribing pain medications.

Why? Well, according to this article California’s “another great idea from stupid people” came as a suggestion to tighten down on prescribing pain medications as “a challenge to reduce the cost of Medicaid ED visits”. What!?! Really!?! To reduce the cost of Medicaid ED visits? Huh? Wait! I guess, maybe, as I cannot really tell but I guess Medicaid cost can be reduced, significantly, I guess, by reducing narcotic prescriptions. I am confused! However, in order to do so healthcare needs another policy. Who knew?

How about just telling patients their condition is not an “emergent medical condition” and they can be seen elsewhere beside the emergency department? I am sure that alone will save Medicaid ED visits and visits for all other insurances as well. Or is the intent to only save Medicaid’s money?

I think NOT! Actually, I know NOT! Because, what about all the roadside billboards that funnel “customers” to emergency departments across the nation? But that is another topic.

Anyhow, California’s “another great idea by stupid people” sounds more like profiling but not going to touch that one with a ten-foot pole. Okay. Okay. If you insist, I will say this and leave it there. If the intent is to save money by curtailing prescriptions for narcotics let me ask, whose narcotic prescriptions are the ones that are going to be cut? Cancer patients? Not likely. Drug seekers? Most likely. Oh, and how many of them are on Medicaid? For the sake of arguing, lets say 100% of the drug seekers. But once they have the prescription of their vise does anyone, anyone, really believe a drug seeker or drug pusher need Medicaid to fill their prescription?

The Numbers: A word problem! Mind you, this is just to show that Medicaid has nothing to do with these policies’ intent.

Online, the average uninsured cost for 120 (YES! ONE HUNDREAD AND TWENTY) tablets of oxycodone/acetaminophen 5mg/325mg is $30. The same website suggest “cutting a higher-dosage pill in half will save 50% or more”. The website also offers a “Discount Coupon”. YES! A coupon. Again, I CANNOT make this stuff up if I tried!

The same website suggesting hydrocodone/acetaminophen as an equally popular choice but cheaper at $17 for 120 (YES! AGAIN! ONE HUNDREAD AND TWENTY) tablets. YES! The website has a “Popularity” scale feature as well that allows the “customer” to compare other choices. To be fair, the “Popularity” scale is available for comparisons of all medicines available and not just narcotics.

All of that just for this, even if I did NOT use Medicaid I can easily afford 120 tablets of my drug of choice for about $30 and my second choice for $17. Not to mention, that if I got a higher-dose tablet and cut it in half I could save another 50% or more, and getting 60 tablets instead would not matter.

So lets say I got 120 tables of 5/325 for $30. Now, in order to be able to afford my next fix, without using Medicaid, I need another $30. With that dilemma in mind I make a “sacrifice” of putting aside 6 of the 120 tablets despite it leaves me with ONLY 114 tablets to get my high. Darn! However, that “sacrifice”, of saving 6 tablets, will easily get me the next fix because on the street those 6 sacrificed tablets will get me the next $30, at $1 per milligram, I need for the next 120 tablets. Medicaid or not.

Now, if the intent is to sell, $30 for 600mg of hydrocodone total is a steal, even without Medicaid. Why? That is a $570 return on $30 or almost 2000% return and that is from one prescription. Divided that by an 8-hour day that is $71.25 per hour. “Tomorrow I guess I will do the same. Oh, what the hell I still have all day I might as well just drive across town and try to score another prescription.” Not to mention, a number of drug-seekers are shopping for a ringleader who they support.

That is as far as I will go with that train of thought, or lack of.

Having opened that can of maggots [sic], lets move on to what I would rather address instead and what I guess was an afterthought, semicolon and all, in the article and as catalyst to “another great idea from stupid people”. On that note, the second reason for “another great idea from stupid people”, after the Medicaid smoke screen, semicolon and all, was to control narcotic prescriptions. The article stating, again, after a semicolon, “of course” because narcotic overdoses have reached an all time high. Really? That shocking fact is news? NOT!

In a previous blog (2012), I not only mention that narcotic overdose had reached an all time high, but worse, that DEATHS from narcotic overdose had surpassed automobile crash related deaths. That has been a fact since 2008 and a recorded public known fact since 2011. So, narcotic overdoses being the reason for the season, oops, the reason for these policies is CRAP!

Keep in mind; automobile crash related deaths have been our nation’s leading cause of death for generations, not just decades, generations. With drug-induced deaths being tracked by the CDC only since 1979. Yet, this article did not mention the fact that drug-induced deaths had surpassed automobile crash related deaths at all. Not that its mention really matters. Because as I mentioned in a previous blog, no one has been moved by the fact that automobile crash related deaths had lost its number one place to medication overdose anyhow. However, I would think that any attempt to bring the tragedy of overdose deaths to the forefront one would want to make some comparison. Those two, automobile crash deaths versus drug-induced deaths, in my opinion, being a good comparison as our nation has more people driving than the number with access to narcotics. Well, now that I have written that I would have to admit that is not a fact I know but simply a hope of mine. What I do know is that “Healthcare providers wrote 259 million prescriptions for painkillers in 2012, enough for ever American adult to have a bottle of pills.”

Having said that, I guess the article is trying to capture someone’s attention when it compares narcotic overdose related deaths to the latest healthcare media frenzy, Ebola. In doing so the article compares the daily 28 deaths caused by Ebola to the daily 75 deaths due to narcotic overdose. Will it get anyone’s attention? I think not!

Nonetheless, I applaud the article for trying to get someone’s attention, as those facts should move anyone. However, I do not see it catching anyone’s attention either as I am sure the media is well aware that motor vehicle crash deaths were dethrone by drug-induced deaths yet “nada”, nothing! Because of that, I question whether this far-reaching comparison might get their attention either. Because despite the media’s attention on the Ebola drama, Ebola is still far away, literally, in countries 99% of us will never travel to and from where so few from those countries will come here. However, the exotic features of such a threat does sell newspapers and why they cover it.

Having said that, I would add, that even if Ebola did find its way to the USA, overdoses from narcotics would still kill more EVERY day than Ebola, there or here. Yet, I still do not believe narcotic overdose would be addressed.

So then, why is healthcare trying to make a case to police narcotic prescribing? Call me cynical but it is NOT because narcotic overdose death rates have “increased six fold from about 6,100 in 1980 to 36,500 in 2008” or that deaths have MORE THAN TRIPED since 1990 to 2014.

Nonetheless, I applaud any intent to get narcotics under control. However, that is not the reason why it is being addressed and those claims of controlling Medicaid cost and saving lives are nothing more than smoke screens. How dare I? Easy. Because not prescribing ANYTHING, that includes antibiotics, MRIs or work absence notes, is as easy as 1-2-NO! That two-letter word is all “concerned” healthcare workers have to say, “NO!” Done! Easy peasy!

But NOOOooo! Instead, the reason for this “other great idea from stupid people” is BECAUSE healthcare pundits believe that any change in the practice of prescribing narcotics will affect patient satisfaction scores! And no healthcare administrator wants that collateral damage as it could cost them their job if their organization’s satisfaction scores fall below the score of those “up the street”.

Instead, they came up with “another great idea by stupid people” and hide behind such idiotology [sic] so it looks like they are doing something to resolve the overdose issue. Not to mention, it makes them look “caring and compassionate” too. BULLSHIT!

My point: By putting up this “Safe Pain Medicine Prescribing in the ED” smoke screen CRAP(!) healthcare pundits can dismiss the complaints they blame for the bulk of poor customer satisfaction scores, drug-seekers. However, although I repeat myself, drug-seekers do not, in general, impact satisfaction scores. Having said that, it will be this latest idiotology [sic] that will finally prove that to our industry’s subject matter experts when the numbers come in and nothing has changed. But, who am I to warn them?

Playing devil’s advocate, I thought pain was an individual experience and whatever the patient said was their pain was their pain, PERIOD! But these discharge instructions now state, “Our emergency department will only provide pain relief options that are safe and correct. We use our best judgment when treating pain.” If so, what did we do in the past? Were we not using our best judgment? Not to mention, what happens when the patient says, “OxyContin is the only thing that works for my pain”? I guess these policies debunk previous claims of pain being a personal experience as the intent of these policies is that pain complaints will be dismissed if it does not fit the new way of thinking.

Of course critics will say, “The intent of these policies is directed at drug-seekers only and not those with genuine pain.” Really? Because healthcare workers lack prejudice and are experts at distinguishing drug-seekers playing the system from those who are genuine.

Allow me to enlighten those experts, drug-seekers, as the addicts they are, are skilled manipulators. Now before critics excommunicate me, let me add that when I say addicts are not patients I mean those not interested in treatment but instead those interested in their next fix. Having said that, bad stuff happens to bad people too. So good luck in trying to separate those with genuine pain versus those looking for a fix!

Now, not as devil’s advocate but as the devil himself, as some have described me, how is this “other great idea from stupid people” any different then my intent to provide safe and correct options and I use my best judgment to treat patients. The difference, I did not have these “other great idea by stupid peopledischarge instructions. Instead, I only had my education and the fact that if I got it wrong it would ONLY be I who would have to face a jury of my peers. Having said that, I guess what healthcare pundits want to share with patients is that these “magical and empowering” discharge instructions are our vetting that we are practicing correctly. OH!

However, these “magical and empowering” discharge instructions are only there for when healthcare workers do not believe a narcotic is the correct treatment plan. So when I decline a patient’s request for an inappropriate antibiotic, x-ray, school/work note, admission, the inappropriate use of the emergency department or whatever other reason those with exaggerated unrealistic emotional expectations complain about I will still be asked to resign, as previously.

Why? Because for those exaggerated complaints there is no “magical and empowering” discharge instructions. Instead, for the unrealistic complaint remains the status quo that we bend over, as exaggerated and unrealistic complaints are not seen as sources of poor satisfaction scores and that is what healthcare administrators want us to believe.

Unfortunately, targeting drug-seekers as the de facto cause of poor satisfaction scores complaints only conceals the genuine collateral damage and cost to healthcare that is accommodating exaggerated unrealistic emotional expectations.

Listed is my two sense [sic] as to why that is when compared to the mentioned article:

*ED discharge instruction sheets will be handed out as if that will be the answer. Because, again, as critics have mentioned, I just keep repeating myself and this one I have mentioned over and over and over, drug-seekers are not patients. They are addicts and addicts do not need discharge instructions, to say the least. Having said that, this Safe Pain Medicine Prescribing in the ED idiotology [sic] is not about healthcare but about dismissing drug-seekers from getting a customer experience scorecard.

To those not paying attention, this tactic is no more than a deflection, just like the one administrator I mentioned in the book who expected finance reps to tell patients their condition was non-emergent. A responsibility that is solely of the healthcare worker seeing the patient yet administrators rather finance get the complain over the bad news, that their condition is not an emergent medical condition, versus healthcare workers getting the bad score.

That aside, the discharge instructions by themselves are silly, one through ten.

1.    Disassembled as idiotic above. Do healthcare workers really have to mention, in writing nonetheless, that we follow legal and ethical advice? What other option is there? It really is not necessary to state the obvious. Unless, of course, you are placating in hopes to avoid a patient complaint. Having said that, are patient complaints really that significant over the great medical care provided?

2.    Again, directed at patients. Addicts do not need your scolding. They will just go elsewhere or recruit a “patient” who will present a better picture.

3.    Again, fine with addicts…a limited amount here…a limited amount there…

4.    Thanks for letting me know so that I can come up with another story.

5.    That’s fine too. Whatever I can get until I hit the mother load.

6.    Again, thanks for letting me know so that I can come up with another story…or, again, I will take whatever I can get until I hit the mother load.

7.    Once again, thanks for letting me know. But this time I will take that by mouth instead and cheek it so that later I can melt it down and give myself a shot later. Maybe you will give me a limited amount too instead of the one shot.

8.    Again, addicts do not care about laws or ethics but thanks for letting me know so that I can come up with another story.

9.    Because healthcare workers are SO trained in identifying fake IDs. On the contrary addicts are master manipulators and ID is not something they are short. So not a problem! What state do you want it from?

10. Huh! There! You finally got them! NOT SO! See #9. What name would you like today? Two more things about the pharmacy data banks. One, bad stuff happens to bad people. Two, I would NOT place my decision on a data bank on whether or not I am going to prescribe a narcotic or not. Instead, I would do so based on my HPI and findings only.

EMTALA is for emergent medical conditions PERIOD—everything else is because we do not want to say NO. I know. I know. Some will say that pain is an emergency. NO! Pain is the 5 vital sign, and “another great idea from stupid people”. No vital sign by itself is an emergency, Temp 101.4 NOT! Pulse 110 NOT! Respiratory rate 24 NOT! BP 170/96 NOT!

So why would pain be an emergency? NO ONE HAS EVER DIED OF PAIN, acute or chronic. And again as I have said a number of times, in the book and this blog, drug-seekers’ pain is never a pain I would consider narcotics for anyhow, like, headache, tooth pain, muscle or skeletal pain (unless a fracture), yada, yada, yada.

Discounting pain as an emergency is uncaring and lacks compassion critics say. NO! Those thought are nothing more than accommodating because that is what healthcare does. Instead, those manipulating persons, drug-seekers and those with exaggerated unrealistic emotional expectations, are no more than taking advantage of our helping and accommodating hearts.

For example, this is what I tell patients seeking refills, narcotic-seekers or not, “Every bottle of medication runs low…weekend or not…make the arrangements…do not wait until you are out of medicine to get a refill.” It really is that simple. On that note, why is it that I rarely, like less than ten patients in thirteen years, seen patients who are on Metoprolol, Albuterol, Viagra, Nexium or any other non-narcotic drug looking for refills in the ED? To those ten in thirteen years I said the same, “…make the arrangements…do not wait until you are out of medicine to get a refill.” So please, save me the cry that EMTALA requires us to refill medicines from the ED as will!

Quit bowing to JCO! Yea! Yea! Yea! I know. Every body wants to be accredited and why healthcare is nothing more to JCO than JCO’s little !ITCH! Wiping every seat before JCO sits. Makes me sick!

DITTO, quit bowing to patient satisfaction scores! Which, where, who, why, what, when, and how gave this “another great idea from stupid people” legs. Yet, somehow the mention of patient satisfaction scores did not find itself into the mix in the mentioned article until the last listed in the article. Well in front of “and the like”. “And the like” of what? How pathetic!

The proposed measure in the article also includes tips like:

“Helpful safe prescribing tips and a physician education tool about how to communicate these guidelines to patients, as well as a sample letter to medical staff, use of CURES (California’s Prescription Drug Monitoring Program database), and a number of published resources covering opioid drug prescribing and abuse.”

Why? Because of all the drugs healthcare workers prescribe we need help with narcotics. NOT really!!! It’s just that healthcare pundits cannot sell “another great idea from stupid people” without them making those claims, like healthcare workers need help with “how to communicate”.

For the sake of argument, lets entertain the idea that healthcare workers do need help with communicating. However, here it is not in the sense of “how to communicate” but rather “how to communicate without offending those who seek narcotics”. Why? Because. Wait for it. Wait for it. Addicts will give you a poor satisfaction score if you just say NO without the support of this “magical and empowering” politically correct discharge instruction sheet. Which is what all this latest “another great idea from stupid peopleis really all about, avoiding poor satisfaction scores, and nothing to do with the daily number of deaths cause by narcotic overdoses. One would think that narcotics are a new thing and why anyone, ANYONE, would suggest that healthcare workers need remedial TIPS on how to safely prescribe them.

Has anyone put any thought into this? These are medicines (methadone, oxycodone, hydrocodone) have been on the market for more than half a century, YES! MORE THAN HALF A CENTURY, with the newest narcotic being Nucynta in 2009. So then, what is so different about prescribing narcotics that have been around for MORE THAN HALF A CENTURY?

Not to mention that it was not until the early 90’s that drug-induced deaths began to climb. So what is so different about these same MORE THAN HALF A CENTRY old drugs? Nothing! Absolutely NOTHING!

Wrong! I stand corrected. There is ONE(!) difference or change in prescribing narcotics since the early 90’s and that is the lack of testicular fortitude that comes with catering to CUSTOMER SATISFACTION! Again, NOT NEWS! If anything, redundant and tiring to have to say the same over and over. Not by me but by others, as so many articles have been written about customer satisfaction in healthcare and those articles ALWAYS mention healthcare workers placating to drug-seekers.

Why? Because, if it was not for drug-seekers those healthcare workers would NEVER have a single complaint against them. I do NOT believe. In the book I mention a number of healthcare workers who are the epitome of customer service yet patients complained about them and none of those incidents were about drugs but simply exaggerated unrealistic emotional expectation that were not catered to. So for healthcare workers to claim their only complaints come from drug-seekers I do not believe that. What I do believe is that drug-seekers are nothing more than scapegoats and why it is VERY likely any healthcare worker asked will single out drug-seekers as to why that healthcare worker got a poor customer satisfaction score. Again, I disagree that drug-seekers are the only ones who complain but that is the common answer and why this latest “another great idea from stupid people” has emerged.

Having said that, the second paragraph of the mentioned article may have let the cat out of the bag.

“This approach addresses some of the concerns about the adverse impact of reductions in the distribution of narcotics through the ED on patient satisfaction scores, and reduces the likelihood that non-participating EDs in the area will be flooded with patients seeking drug prescriptions for non-medical use.”

Oh, so it is about reducing the distribution of narcotics to drug-seekers after all and not so much about narcotic-related overdoses and deaths. I knew it! However, and once again as I have said so many times before, denying drug-seekers narcotics is not going to affect the customer experience one way or the other. Instead, as I mention in the book, these idiotologies [sic] lead to blinders, if not prejudice, which I caution healthcare workers about for no reason other than “bad stuff happens to bad people as well”.

Unfortunately, the article goes on to support this “another great ideas from stupid people” by stating, “This policy on Safe Pain Medication Prescribing in the ED is emergency medicine’s contribution to confronting this crisis, and EVERY emergency department in the country should be climbing on board this bus.” Which crisis, the overdoses and the related deaths or the drug-seeking habits and the poor satisfaction scores?

Giving this author the benefit of the doubt, I believe the author of this article is misled, just like those who bought into the MANY “other great ideas from stupid people”.

Unfortunately, I have heard that idiotology [sic] before. This being “another great idea from stupid people” and just one of MANY that got us where we are today with regard to the customer experience, suggesting to put customer service before medical care.

Because, as I have stated over and over again, addicts do not care or contribute to customer experience surveys, regardless if not intentionally excluded. Having said that, it would be more economical, among other things, if healthcare workers just said, “NO!” and skipped the discharge instructions. However, those healthcare workers need those discharge instructions they can point to because they lack the testicular fortitude without them.

Again, the article states, “This policy on Safe Pain Medication Prescribing in the ED is emergency medicine’s contribution to confronting this crisis, and EVERY emergency department in the country should be climbing on board this bus.”

Again, I have heard that idiotology [sic] before and that is the same CRAP(!) from healthcare pundits, influenced by outsiders, that the “customer satisfaction” train has left the station and we need to be on that train or pay the consequences. Now that is what is redundant not to mention “another great idea from stupid people”. Because despite the “customer satisfaction” train is headed down the WRONG tracks no one is willing to do anything about correcting that misfortune.

YES MORE CRAP! Because healthcare lets others tell us what to do and we are so blinded by our desire to help others that we miss the hidden agenda of outsiders. None of these “great ideas from stupid people” are about patients as much as they are a compromise to the patient satisfaction movement that continues to take healthcare down the wrong tracks. Or bus, I guess, as this last article labels it.

Bottom line, these are addicts, not patients, that healthcare is trying to accommodate without offending. Why? Why do we continue to bow? How about simply making a list for when to prescribe narcotics and when not too? Like:

YES                                                                             NO!
Fracture                                                                      Strain/Sprain (Back included)
Corneal Abrasion                                                        Headache
I&D                                                                              Ear, throat, tooth pain
Burn 2                                                                         Abdominal pain
Miscarriage pain                                                         MVC pain except fracture
Shingles’ pain                                                             Laceration/Abrasion
Cancer pain                                                                Chronic pain or refills

A simple list INSTEAD(!) of having to explain, in writing, that we are using our best judgment following legal and ethical advice. Or having to check everyone’s ID or tell anyone they have to get their care from one provider and one pharmacy. Or that we will only give a limited amount of by mouth short acting medicines only and that none of them will include stolen or missed prescriptions. Or waste time having to request medical records or look up anyone’s dispensed track record on some databank.

Do we not already have enough things we have to manage all at once? Yet for the sake of the customer experience, and not medical care, healthcare administrators want us to waste the most time on those who need it the least.

Yet, I can hear critics stating that “another great idea from stupid people” can be used to divert potentially complaining patients.

Oops! That’s not what they would say in public. What I meant to say was, I can hear critics stating that it is beyond my understanding that “another great idea from stupid people” can be implemented “with the patient’s best interest in mind”, of course, and also as a solution to prescribing narcotics inappropriately. "Wink. Wink."

Of course, I guess my misunderstanding of healthcare pundits is possible. Especially since to me it is SO obvious and nothing more than another example of the lack of testicular fortitude in healthcare of which outsiders take advantage and get healthcare workers to bend over or be dismissed.

Again, just my two sense [sic].

While at it get rid of the pain scale too! “Another great idea from stupid people”!

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