Pain, privacy, and safety

Abel over at TerraSig dug up an interesting story about a man who was “murdered” killed rendered not-living (in the moral if not legal sense) by a “fake chiropractor” (although it’s not clear to me what science separates a “real” from a “fake” chiropractor). One of the commenters wondered if lack of health insurance had driven the man away from standard medical care. Another bemoaned the inadequacy of treatment for chronic pain conditions.

This got me thinking…

In the case of the fake chiropractor, I’m guessing that many factors went into the decedent’s seeking this particular care. Perhaps insurance was an issue, but I wonder (knowing nothing about the patient) whether community referrals, cultural practices, or immigration status might have played a role. Certainly, as mentioned in some of the comments, cost sometimes drives people to unconventional care, but seeing alternative practitioners doesn’t necessarily save money. I have had many patients buy medicine on the street (often antibiotics) to save themselves from a doctor’s visit. National health insurance could fix some of these problems, but if someone from rural Michoacan decides to visit a curandera, the issue is much more complex.

All that aside, the treatment of chronic pain is a tough issue. There are a number of chronic pain conditions that we understand very well, and a number of them that we do not. Complicating matters is that pain is most often completely subjective, drug abuse is common, and there is a vigorous business in diverted pharmaceuticals. But should those in pain suffer from the sins of others?

Of course not, but it is inevitable. Something always has to give. For example, in my clinic, when we start someone on chronic narcotics, we have them sign a contract that explicitly requires us to take their pain seriously, and explicitly requires them to not seek narcotics inappropriately. Also, the state maintains a database of narcotic prescriptions. I can enter a patient’s demographics and quickly pull up a list of all narcotic prescriptions that they had filled (in a pharmacy!) in the last year.

This, to many, may seem like a violation of privacy. In fact California is currently having a debate about similar issues.

Narcotics are terrific medications. They can relieve great suffering. But our societal problems make it impossible to prescribe them without thinking about the problems of abuse and diversion. I have no problem asking a patient to sign a (non-legal) contract with me, to submit to drug testing, and to have their medication data easily available online. It is a small price to pay.