Thursday, August 25, 2016

Why Are Doctors So Bad With Prescription Opioids?

Since the topic has been in the news again, I thought I'd share my thoughts on the subject.

(This is a teaser adapted from my forthcoming medical memoir/confessional).

When our son was just a year old, he discovered cheese puffs. They're a ubiquitous item at birthday parties for toddlers. Perhaps it's because they dissolve in the mouth and don't pose much of a choking hazard, or perhaps it's because they're a dirt-cheap way to keep kids away from the adult snacks. In any event, cheese puffs were a form of crack to the kid. He'd snatch a bunch of them at a time, saving space in his palm by having them stick out between his fingers. He'd wolf them down until his face glowed neon orange. What do you know...we had found the perfect “special treat"!

One day, we invited some friends over for an afternoon visit, our company bringing their own kids in tow. Besides the big bucket of Thomas the Tank Engine toys, we put out a bowl of cheese puffs for the kids to snack on. Our son grew wide-eyed and dived at his orange, salty beloved treat. When it became clear to my wife and me that he would empty the bowl, spoil his appetite for supper, and likely constipate himself in the process, we took the snacks away.

He threw a fit. I plunked him in the corner for a time out until he smartened up and behaved himself, never mind who put the snacks out in the first place. That was the end of the cheese puffs for our family.

Ladies and Gentlemen, I submit to you modern medicine's approach to chronic pain medication: children and cheese puffs.

Pity the man or woman of modest means in chronic pain. If he or she has no coverage to pay for massages, chiropractic, and braces for various body parts, all that's left is pills. Sedating, constipating, and highly addictive pills.

It takes months to find a pill that works for the patient, and even more months to get to the effective dose. But there's a catch: sometimes the patient will never get to an effective dose, because the prescriber simply won't go above whatever they're comfortable with. And here I'm talking about patients with verifiable, objective conditions that warrant the use of long-term pain medication - backbone fractures, inoperable degenerative disc disease, diabetic nerve damage. Forget the people whose pain is ill-defined, who are well and truly screwed.

But wait! The patient will be expected to sign a contract before receiving a prescription for strong painkillers. The conditions of said contract will include any or all of: random urine drug tests; restriction to one prescriber and one pharmacy; safe storage of medication, possibly under lock and key; and an understanding that any transgression will lead to tapering and/or immediate discontinuation of the drug. Oh, and possible termination of the doctor-patient relationship.

There's still more! Should the pain worsen acutely for whatever reason - weather, heavy housework, a bad night of sleep - the ER will treat the patient's pain only so many times before assigning the patient the label of "drug seeker". This is a de facto blacklist from getting the benefit of the doubt from overworked ER staff.

And finally: should the patient actually agree to all this - and really, what choice does he or she have? - but still screw up in the eyes of the prescriber, the only alternative offered is referral to an addiction centre. There, the patient is guaranteed to be in the company of, and treated as, an addict - a street urchin, the lowest of the low.

This outrageous approach to patients with pain was many years in the making, and nobody has the right answers. Painkiller abuse has become so widespread that managing patients with pain is now inextricably tied to fighting drug addiction. That's fine for society as a whole, but fails miserably at the level of individual doctors and patients. Should I not take the patient at face value for their complaints, in particular if they aren't at high risk for abusing their prescriptions? Am I responsible as a doctor for what the patient does with his or her pills? People don't even take antibiotics properly. And unless I work in Public Health, is it my job to prevent drug diversion, reduce addiction in the community, and fight crime?

So we muddle on, treating people with pain like dirt or turning them away outright. Easier to avoid the headache altogether. Mind you, Percocet works wonders on a headache...

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