There has been a lot of publicity surrounding the increasing use of prescription painkillers and subsequent increase in deaths. In 2014, there were close to 19,000 deaths related to opioid painkiller overdose. State and federal governments have reacted with various initiatives, from changing the scheduling of Vicodin, to initiating prescription drug–monitoring programs, to limiting the number of pills dispensed. There are loud voices on either side of this debate, to be sure, but perhaps none so aggravating as the aggravated patient.
I did not start my practice with any prescribing “policy,” as I thought such policies were arbitrary. I am a physician, after all, so why wouldn’t I prescribe a narcotic if necessary? I also trained at a time when pain was considered “the fifth vital sign,” and we were taught to treat it aggressively.
But after a while you learn that trust in patients can be misplaced. You never forget the first nice lady whose urine drug screen comes back negative when you expected it to show the narcotic that you were prescribing her. You never forget the person who calls on a weekend claiming to be a patient of the practice and turns out not to be. And when your colleague gets her DEA number stolen and her signature forged, you finally learn that humanity is imperfect. What’s more, in your transition from young naive doctor to elder statesman, you learn that the push to treat pain so aggressively was achieved, in large part, by lobbying from the pharmaceutical industry.
Some patients of course can have a legitimate need for narcotics and truly derive benefit from them. In such patients, it is our practice to have the patient sign a pain “contract.” Such contracts are nonbinding, but give the narcotic prescription the gravitas that it deserves, underscoring the sacrosanct nature not just of the prescription but also of the physician-patient relationship. They specify the strength of the prescription, the number of pills dispensed, the pharmacy at which the prescription is to be filled, and the physician’s prerogative to do random drug screens.
The more vexing problem for rheumatologists involves patients with central sensitization and chronic pain. These patients seem predisposed to requiring escalating doses of narcotics, and they often have risk factors for developing narcotic abuse disorders. In addition, there is no evidence that chronic narcotic use provides any long-term benefit. But it is a rare chronic pain patient who is willing to accept that narcotics are not the answer to his or her problems.
One way to manage this is for the patients to not be given narcotics in the first place. That probably requires lobbying of a different kind: educating primary care providers and emergency department physicians on how to recognize chronic pain or central sensitization syndromes and disseminating the literature showing that narcotics have no long-term benefit in such cases.
Dr. Chan practices rheumatology in Pawtucket, R.I.
