Monday, November 7, 2016

What It's Like To Treat Chronic Pain Patients

Because politicians and pundits haven't a clue.

Sometime in the last 20 years, after unethical marketing practices by drug makers and a change in the clinical zeitgeist towards chronic pain, society decided that a doctor's approach to treating individual pain patients is fair game for public reprimand, before investigation and without charge of wrongdoing. I'm not sure when it happened or how it happened, nor how it is that this shaming only applies to chronic pain.

If I'm overzealous in the prescription of blood pressure pills, pushing my patients' readings below the recommended targets, and the patients subsequently die from kidney failure or a fall, am I not guilty of malfeasance? If I insist my diabetic patients get their sugars into the 4-6 "target" range, in spite of substantial evidence that such an approach causes more harm than good, and some patients die of hypoglycemia, why am I not being charged with malpractice, or even a crime? Why is mistreating chronic pain worse than mistreating any other disease or condition?

There's a bigger problem with the current witch hunt targeting opioid prescribers, and it's not even the claim that overprescription of opioids is the primary cause of overdose deaths. The problem is that it overlooks a simple truth: statistics and guidelines are almost meaningless at the level of the individual patient.

A woman came into my practice having her chronic pain treated to date by specialists and walk-in clinic physicians. Her dose of opioid on the day she came into my care was over 1 gram of Oxycontin in a day...that's the equivalent of 200 Percocet tablets, every single day. After 6 months, I was able to take her off maybe 10% of that total, and she could not tolerate life at a single milligram less. This was after she'd had surgery, physiotherapy, chiropractic, and every non-opioid drug under the sun. She worked full-time and was a caregiver to her sibling.

If I continued her prescription, I'd be in violation of any accepted guidelines. And according to the government, I might be guilty of misconduct, of flooding the streets with mis-prescribed drugs. I'd deserve professional investigation, if not sanction.

If I refused to renew her script, and demanded her medications be reduced further, I'd please the government, the College, the authors of guidelines, and probably my own doctor (it would do wonders for my blood pressure). But my patient could justifiably say I'm disregarding her in the name of pleasing these institutional bodies that have no idea of how she lives, nor how she feels each day.

What course of action is the "right" one?

Another woman returned to my practice, having moved out of province for a few years. She had a terrible history of addiction, but in her two years away had ditched her problematic boyfriend and weaned herself off methadone. Unfortunately, she was diabetic, and in the interim years developed intractable pain in her legs from nerve damage. She tried all the usual pills but they didn't work - they never work - so I agreed to try her on opioids. I kept her (pardon the demeaning metaphor) on a very short leash. She needed to take her dose at the pharmacy, witnessed by the pharmacist every single day. After a few months, I gained enough trust in her to let her have weekly dispensing of her prescription. Her dose needed to be titrated, but never approached the recommended limits. And she felt better.

Did I practice good medicine? We're talking about a patient with every red flag under the sun. Should I not have simply refused, and let her languish? Who benefits by letting her spend the rest of her days in untreated pain? What if, after adhering to her "contract" with me, submitting to urine tests and so on, she socializes once more with the wrong people and ends up dead by overdose? Am I responsible for her death? I'm the one that put her back on opioids, after all, in spite of the red flags in her own history.

If you think these situations are unique, they aren't. I'd wager that just about every general practitioner in the country - probably in the entire developed world - and many specialists face these sorts of situations every day. The same holds true for other conditions treated with habit-forming medications like anxiety and insomnia. I know I've lost sleep over these and similar patients, as has my wife, and as have many colleagues that are far better doctors than I could ever be.

Laws and regulations are rather crude instruments at government disposal. They are extremely effective when a clear line must be drawn, or when dealing with situations that are amenable to objective judgement: you've either driven within the speed limit or you haven't; the milk is either pasteurized or it's not. To apply the same kind of approach to the very human and therefore messy practice of medicine is wrong-headed, and potentially irresponsible. Worse still, it will be the patients in the end that suffer most.

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