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The streets are dry
The Journal of Emergency Medicme. Vol IS. No 4. pp 543-54-l. 1997 Copyright 8 1997 Elsev~er Saence Inc. Printed ,n the USA All rights reserved 0736-4679/97 $17 ofl A 00
ELSEVIER
PII so736-4679(97)ooo91-7
THE STREETS ARE DRY Richard P. O’Brien, Reprint Address:
Moses Taylor Hospital, Scranton, Pennsylvania Richard P. O’Brien, MD, Moses Taylor Hospital, 700 Quincy Avenue, Scranton,
“The streets are dry,” 1 heard two people say in the emergency department (ED) hallway. “Good,” I thought, “it is busy enough here tonight without slick streets.” The ambulance band comes alive suddenly with the report of an incoming 20-yr-old man immobilized due to severe nontraumatic back pain, “otherwise very healthy. ” “We may have to hold him in the hall until a room is free; we’re packed tonight,” says the charge nurse. “Your next patient, doctor, is a woman with the worst headache of her life,” a woman who tells me, “I don’t need any tests. I’ve had them all.” The patient is not very happy with my nonnarcotic approach to migraine, and then suddenly remembers she is allergic to multiple medications. The ambulance arrives with a young, athletic-appearing man, who is remarkably comfortable lying on a hard backboard in the hall with his “paralyzing” back ache. I apologize to him for the wait: he says, “No rush, dot.” The X-ray studies ordered in the waiting room on the next patient show a small fracture of the fibula in a middle-aged woman. Yet. her leg looks as if it has already been wrapped, with curious wisps of cotton and powder on her skin. “Has this leg been put in a cast,” I start to ask her. “Yes, at the Walk-In, and they wouldn’t give me anything for pain so 1 took the damn thing off and came here!” She admits this only after a great deal of discussion that I politely refer to as the ultimate in circumlocution. Now that the clinics are closed, I surmise, she has graduated to hospitals. Two nurses are talking to a police officer investigating
RECEIVED:
6 December 1995; FINAL SUBMISSION 16 December 1996
RECEIVED:
PA 18510
an assault case, and I hear him say, “The streets are dry.” He says, “It’s supply and demand, we’ll see more of this tonight.” After some admirable work by several law enforcement agencies in the last few days, I find out there has been a great deal less heroin on the streets. Looking back at the last few shifts I have worked, I have seen many patients with unusual histories of acute pain. I wonder how many of those were legitimate. I never took an economics course, but I distinctly remember physics. In the ED, for every action there will be an equal and opposite reaction. I would like to believe it is difficult for drug-seeking patients to take advantage of us. I am indignant at the thought that drug seekers may keep us busy while the acutely ill have to wait. Abruptly, I catch myself not wanting to prescribe narcotics for a friend’s husband who is clearly passing a kidney stone. The idea of withholding relief to someone suffering tears me up even more than supplying the dependent with more of an addictive substance. The ED is on the receiving end of many of society’s woes. Nights like this one illustrate how we are profoundly affected by well-meaning attempts at choking the supply of illegal drugs in the misguided hope that the demand will naturally dry up as well. I admit to assuming the posture that the clinical circumstances must demonstrate an unequivocal need for opiates before I will consider their administration. I look for red flags such as multiple nonnarcotic allergies, comments such as “Nothing works but the DemeroP,” and overconcern about the number of milligrams injected or
Humanities and Medicine is coordinated by Richard Medicine, Farmington, Connecticut ACWPIED:
MD
M. Rarzan. MD, of the University of Connecticut School of
25 November 1996; 543
544
the number of tablets prescribed to form my impression. Without being stingy, I use no more than a reasonable dose of any potentially addictive medication and call in all controlled substance prescriptions to avoid illicit computer-generatedcopies appearing all over town (a previous experience I never wish to relive). I feel no reasonableperson should object to a trial of nonaddictive therapy in the ED, especially if it is potentially safer and equipotent. If a calm and empathetically delivered discussion of treatment options results in a malignant display by a patient, my suspicion of opiate seeking is maximized, especially if the patient is expending more energy and effort in the pursuit of narcotics than on their clinical concerns. Society must also assumeits own posture. We cannot slow down the supply of drugs to addicts and declare victory. Our goal has to be nothing less than to raise a full generation of children who equate substanceabuse
R. P. O’Brien
with tragedy; youngsterswho will not be tempted by the perverse economics of dealing in street drugs. The war on drug abusewill not be won with slogans and platitudes. I suggest that it will not be won by enacting piles of new legislation. It has not been won by our laborious efforts to date. This war will be won in the home. Parentseducatetheir children as early as possible to respect a hot stove, electricity, and household chemicals. No child is born with an innate fear of stray animals and moving cars. Responsible adults do not allow children to encounter these perils until they have established a fundamental trust that the child will avoid suchjeopardy. Children must have this basic knowledge long before their first day of school. If parents can raise children who have a life-long avoidance of bee stings and respect for electrical outlets, surely we can raise children with a healthy fear of drug abuse.Only then will the demandfor drugs diminish and will the streetsbe dry.
ELSEVIER
PII so736-4679(97)ooo91-7
THE STREETS ARE DRY Richard P. O’Brien, Reprint Address:
Moses Taylor Hospital, Scranton, Pennsylvania Richard P. O’Brien, MD, Moses Taylor Hospital, 700 Quincy Avenue, Scranton,
“The streets are dry,” 1 heard two people say in the emergency department (ED) hallway. “Good,” I thought, “it is busy enough here tonight without slick streets.” The ambulance band comes alive suddenly with the report of an incoming 20-yr-old man immobilized due to severe nontraumatic back pain, “otherwise very healthy. ” “We may have to hold him in the hall until a room is free; we’re packed tonight,” says the charge nurse. “Your next patient, doctor, is a woman with the worst headache of her life,” a woman who tells me, “I don’t need any tests. I’ve had them all.” The patient is not very happy with my nonnarcotic approach to migraine, and then suddenly remembers she is allergic to multiple medications. The ambulance arrives with a young, athletic-appearing man, who is remarkably comfortable lying on a hard backboard in the hall with his “paralyzing” back ache. I apologize to him for the wait: he says, “No rush, dot.” The X-ray studies ordered in the waiting room on the next patient show a small fracture of the fibula in a middle-aged woman. Yet. her leg looks as if it has already been wrapped, with curious wisps of cotton and powder on her skin. “Has this leg been put in a cast,” I start to ask her. “Yes, at the Walk-In, and they wouldn’t give me anything for pain so 1 took the damn thing off and came here!” She admits this only after a great deal of discussion that I politely refer to as the ultimate in circumlocution. Now that the clinics are closed, I surmise, she has graduated to hospitals. Two nurses are talking to a police officer investigating
RECEIVED:
6 December 1995; FINAL SUBMISSION 16 December 1996
RECEIVED:
PA 18510
an assault case, and I hear him say, “The streets are dry.” He says, “It’s supply and demand, we’ll see more of this tonight.” After some admirable work by several law enforcement agencies in the last few days, I find out there has been a great deal less heroin on the streets. Looking back at the last few shifts I have worked, I have seen many patients with unusual histories of acute pain. I wonder how many of those were legitimate. I never took an economics course, but I distinctly remember physics. In the ED, for every action there will be an equal and opposite reaction. I would like to believe it is difficult for drug-seeking patients to take advantage of us. I am indignant at the thought that drug seekers may keep us busy while the acutely ill have to wait. Abruptly, I catch myself not wanting to prescribe narcotics for a friend’s husband who is clearly passing a kidney stone. The idea of withholding relief to someone suffering tears me up even more than supplying the dependent with more of an addictive substance. The ED is on the receiving end of many of society’s woes. Nights like this one illustrate how we are profoundly affected by well-meaning attempts at choking the supply of illegal drugs in the misguided hope that the demand will naturally dry up as well. I admit to assuming the posture that the clinical circumstances must demonstrate an unequivocal need for opiates before I will consider their administration. I look for red flags such as multiple nonnarcotic allergies, comments such as “Nothing works but the DemeroP,” and overconcern about the number of milligrams injected or
Humanities and Medicine is coordinated by Richard Medicine, Farmington, Connecticut ACWPIED:
MD
M. Rarzan. MD, of the University of Connecticut School of
25 November 1996; 543
544
the number of tablets prescribed to form my impression. Without being stingy, I use no more than a reasonable dose of any potentially addictive medication and call in all controlled substance prescriptions to avoid illicit computer-generatedcopies appearing all over town (a previous experience I never wish to relive). I feel no reasonableperson should object to a trial of nonaddictive therapy in the ED, especially if it is potentially safer and equipotent. If a calm and empathetically delivered discussion of treatment options results in a malignant display by a patient, my suspicion of opiate seeking is maximized, especially if the patient is expending more energy and effort in the pursuit of narcotics than on their clinical concerns. Society must also assumeits own posture. We cannot slow down the supply of drugs to addicts and declare victory. Our goal has to be nothing less than to raise a full generation of children who equate substanceabuse
R. P. O’Brien
with tragedy; youngsterswho will not be tempted by the perverse economics of dealing in street drugs. The war on drug abusewill not be won with slogans and platitudes. I suggest that it will not be won by enacting piles of new legislation. It has not been won by our laborious efforts to date. This war will be won in the home. Parentseducatetheir children as early as possible to respect a hot stove, electricity, and household chemicals. No child is born with an innate fear of stray animals and moving cars. Responsible adults do not allow children to encounter these perils until they have established a fundamental trust that the child will avoid suchjeopardy. Children must have this basic knowledge long before their first day of school. If parents can raise children who have a life-long avoidance of bee stings and respect for electrical outlets, surely we can raise children with a healthy fear of drug abuse.Only then will the demandfor drugs diminish and will the streetsbe dry.