LOUISIANA PUBLIC HEALTH ASSOCIATION
MRSA (Methicillin Resistant Staph Aureus) And Heroin: The Doctor’s Dilemma
Perhaps you are wondering what MRSA and heroin have in common and why either would pose a dilemma to a physician. What is this dilemma and what do these two things have in common?
MRSA (Methicillin Resistant Staphylococcus Aureus) is a germ that plagues health care providers and institutions. Staphylococcus aureus lives on skin and is found to varying degrees on most people. In itself, it is fairly harmless, but can cause superficial wound infections in some individual and life-threatening septicemia in others. Staphylococcus aureus was originally sensitive to penicillin, the miracle antibiotic of the mid-20 th Century. Within a few years, however, Staphylococcus had developed resistance to penicillin following its widespread use. What eventually resulted was a race over time between pharmaceutical companies and the germ. Staphylococcus developed resistance to a host of newly developed antibiotics, first methicillin, and subsequently a number of others. Now, especially virulent MRSA organisms (often found in health care facilities) are resistance to all but very few expensive antibiotics whose use is restricted to infectious disease specialist.
During this same time, MRSA moved from the hospital and nursing home out into the general community where it can be contracted by athletes and others. Both the hospital acquired and community acquired versions of MRSA can be combatted by measures of hygiene and what is called “antibiotic stewardship,” or the judicious use of antibiotics, notably abstaining from their use unless it is really necessary.
Heroin seems like another topic entirely, and yet the heroin epidemic in the United States has largely grown out of the overuse of pain medications, prescribed by doctors for various conditions. Almost every heroin addict, of which there are hundreds of thousands, started with pain medications prescribed to them legally. When unfortunate individuals becomes addicted, alleviation of symptoms is achieved either through using more legally or illegally obtained prescription medications or switching to street drugs, most commonly heroin because of its low cost and availability.
MRSA and heroin use only have in common that they have their origins in the injudicious use of antibiotics in one case and pain medications in the other. Since both are prescription medications, it requires a doctor to write the prescription in the first place. If doctors know the dangers posed by overuse of either antibiotics or pain medications, then why are they being over- prescribed? Therein lies the “doctor’s dilemma.”
A patient with an infection (often a cold or upper respiratory infection) often expects or demands an antibiotic as treatment. Sometimes it is justified, but often it is inappropriate. Viral infections do not respond to antibiotics and often run their course regardless of the treatment. The doctor must decide to spend twenty minutes going into a difficult discussion of the importance of not giving unnecessary antibiotics (i.e. “antibiotic stewardship”) or spend two minutes writing an antibiotic prescription which may contribute to developing a resistant germ. From a purely economic standpoint, twenty minutes vs. two minutes is a no-brainer. In addition, a disgruntled patient often goes to another provider to get the antibiotics they think they need. And heaven forbid that the patient worsens without antibiotics and develops a bacterial infection with complications. The doctor becomes subject to litigation for “failing to diagnosis and treat.”
Pain medications pose the same dilemma. A patient with a low pain tolerance, especially who has been previously treated with highly effective (and highly addictive) pain medications, will often request a specific brand of narcotic pain medication. It takes the doctor twenty minutes (or more) to explain the dangers of narcotic use and two minutes to write a prescription. The doctor also knows that the patient can and will seek another more compliant provider if they are refused. Although the doctor can query Louisiana’s Prescription Monitoring Program (PMP) to track narcotic medication use, it is not required for regular physicians to do so at this time.
So the doctor confronts and resolves the dilemma as best he or she can. Do they want to spend the additional time to withhold antibiotics and pain medications, or do they capitulate and do the wrong thing from an ethical and medical standpoint? The proliferation of resistant organisms and the epidemic of heroin use across the United States speaks for itself. Aggravating the doctor’s situation is the ubiquitous expansion of “Patient Satisfaction Surveys.” Pleasing patents is often the condition for continued employment and advancement. While there is nothing wrong with being a pleasant, helpful, informative doctor, there are times when not giving the requested treatment or test is the ethical and medically correct thing to do.
Patients and physician are both complicit in the abuse of antibiotics and the abuse of pain killing medications. Since we should be partners (and not adversaries) in health care, it remains to both the medical community and the larger patient community to understand that sometimes withholding antibiotics and narcotic pain medication is just the right thing to do. Let’s all be part of the solution and not part of the problem.
David J. Holcombe, M.D., M.S.A.