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.


  1. I live in California, and I would love to see this state adopt a database for checking the history of narcotic prescriptions. Doctor shopping is a dangerous game that can lead to a cycle of addiction (with all the suffering that entails), not to mention lethal drug interactions and overdosing.

    I don’t see the problem with this small “invasion of privacy” if it would save lives and prevent people from becoming stuck in a life of substance abuse.

  2. I understand the “lethal dose” issues, but is restricting access to narcotics really the way to solve anything? I hate to see people misusing any medication, but I would hate it worse to see someone in pain refused access to medication that would help him/her, simply because she has a suspicious history. I think that education is the best way to go. If every doctor briefed the patient on the dangers of narcotic abuse, then it would be in the hands of the patient to do what is right.

  3. spurge

    Ah yes. Lets give up just a few more of our rights in the name of the idiotic “war on drugs”

  4. llewelly

    Records of prior opiate prescriptions are used to send addicts to prison. Is there any evidence prison cures addictions?

  5. It’s a right to keep doctors from knowing what medications you have been on? Wow, I thought patient information should be shared among doctors, but I’m obviously crazy for thinking such things.

  6. spurge

    “Wow, I thought patient information should be shared among doctors, but I’m obviously crazy for thinking such things.”

    It is fine if your Dr. shares info with permission. It is another thing entirely to have your information on a central database that they can see without your permission.

  7. Med surfing is common. It is one reason why many who are addicted to narcotics roam from doctor to doctor and ER to ER. A database collection of what medications a patient is taking is not an unreasonable requirement. It would not only highlight folks who are addicted, and thus need help, but also avoid dangerous interactions between seemingly benign meds.

    Chronic pain is a VERY complex issue. It is only now being evaluated as a comprehensive sptecturm of symptoms. Some of it is psychosomatic, but no less real to the patient.

    I look forward to the day when we have a handle on this modern health issue. I also look forward to the day when there is sufficient confidence in our medical practitioners and compassion from those same practitoners to preclude the seeking of “alternative” remedies.

  8. spurge, it’s not a a unilateral arrangement, prescribing meds. If a doctor prescribes, they take on a responsibility to make sure that there are no dangerous drug interactions, etc. Many patients don’t know their entire med list or don’t think it is important to mention other meds.

    I reserve the right to demand a quid pro quo of sorts: you have the right to deny me access to information, and I reserve the right to show you the door.

  9. spurge


    I understand your point. I didn’t take the Doctors position into consideration.

    Will there be safeguards so that only people who are involved in a patients health care will be able to see it?

  10. In this state, to register for access to the information, you need several identifiers, such as medical license number. After you register, you receive an email to continue the registration process. Once you’ve been confirmed, you have access.

    Each time you access data, you have to certify that you are searching for a legitimate reason, and misuse of the database is considered very, very bad.

  11. spurge

    Thanks for taking the time to explain it too me.

    It is appreciated.

  12. of course, no system is immune from hacking, official or otherwise…

  13. “although it’s not clear to me what science separates a “real” from a “fake” chiropractor”.

    The difference is in 4 years of training, the ability to diagnose the condition and refer out if necessary, knowing when to manipulate and when not manipulate and finally having the skill to do so safely. Very, very few people have been injured by manipulation, of those who have 99% are injured when an untrained or undertrained person (medical doctor, physical therapist, barber, or massage therapist, as in this case) is doing the manipulation.

    Hopefully this will enhance your understanding of the difference.

  14. Steve Bloom

    A “real” chiropractor is… an osteopath.

  15. hi,
    coming to drugs ,drugs are very injurious to health
    drugs will spoils health when people use it continuosly.

    Addiction Recovery California

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