It’s a Pain to Prescribe Pain Medication

Recent events in the media and changes in re-licensure requirements have focused on a long standing controversy in healthcare, the appropriate use of opioid analgesics for pain management.  There are few who would argue that opioid analgesics have revolutionized the care of patients with both acute and chronic pain.  While the effectiveness of these agents in helping manage pain is due in part to their mechanism of action, potency, lack of a ceiling effect and predictable side effect profile, the abuse of this class of medication has clouded the issue of how they are utilized and prescribed.  Nowhere in my almost 50 years of healthcare experience have I previously heard the word “diversion” used in the same sentence as patient care as when opioids are discussed.  It appears that the criminal activity of primarily non – healthcare individuals has directly impacted patient care.  Laws theoretically created to protect the public have resulted in the criminalization of healthcare providers who appropriately used opioids to manage pain and may result in an additional barrier to their use.  The unintended consequence of punitive actions taken against healthcare providers who utilize opioids in their practices is that some have decided to prescribe sub-therapeutic quantities or worse, not to prescribe them at all.  The consequence is that more patients may suffer.

I had the occasion to attend a presentation on the “current use of narcotics and ethical/legal issues.”  The speaker, a pain management specialist, presented an excellent summary of data and the issues surrounding the use of “narcotics” including misuse, addiction, diversion and his personal experience in treating patients in pain.  However, I observed, both in his personal experience, and in the responses from the physicians, and healthcare providers in attendance, during the question and answer period, that healthcare providers frequently initiate the interaction with patients in pain in a somewhat adversarial manner.  The clinical examples discussed by the speaker and audience appeared to stress issues of malingering, difficulty in assessing pain, addiction, diversion and mistrust.  Several physicians stated that they never prescribe more than 30 pills for a narcotic prescription.  For someone in significant acute pain with a self limited illness who requires a dose every 4 hours (the typical duration of many of the short acting opioids), the patient would have to return for another prescription in about a week.

If this was a patient with chronic pain, it would make no sense at all and create another barrier to adequate control of pain and set the stage for a somewhat adversarial interaction with the patient.  I can’t imagine the same atmosphere surrounding encounters if a patient requested an antibiotic for a presumed infection, or requested a specifically named non-steroidal anti-inflammatory medication (NSAID) rather than a generic brand.  Clearly, there are differences between antibiotics, NSAIDs and opioids, but the atmosphere surrounding the interaction and office encounter are quite different.  Antibiotic abuse has resulted in the emergence of “superbugs” immune to many or most antibiotics, and a worldwide health problem, yet most clinicians, the federal government, DEA and State Medical Board do not appear to place the same level of concern on the prescribing of these agents or criminalizing misuse of antibiotics, even when their inappropriate use may have significant and life threatening outcomes.

Even the choice of the term “narcotic” has negative implications and sets the stage for patient apprehension regarding its use.  While it may be necessary to explain to a patient what an opioid is, that discussion can be both enlightening and reassuring to an apprehensive and frightened patient in pain.  It would provide an opportunity to discuss how the medication should be used, the potential side effects, the difference between addiction (frequently feared and misinterpreted and not a common issue with the appropriate use of opioids) and physiologic dependence (a more frequent consequence of opioid use).  It could be an opportunity to reinforce the expectations of both the patient in pain and the clinician.  What does the patient expect and what can I reasonably provide therapeutically.  A reduction in pain, improvement in functional capacity and identifying and addressing potential side effects should surround the use of opioids for both acute and chronic pain.  Pain contracts may be very helpful in formally establishing expectations, particularly where a healthcare provider has concerns regarding a patient’s potential for misusing an opioid.  There is also literature suggesting that it can create a barrier by signifying a mistrust on the part of the clinician.  On the other hand, it has the potential to provide clear expectations of what the clinician is willing to provide to their patients.  It can benefits both parties in this partnership.

In discussing “Ethical Principles” in clinical practice, “autonomy” implies the right of a patient with the capacity to make decisions to accept or refuse specific treatment.  Thus, patients have every right to expect that they would be an integral participant in healthcare decision making.  My personal experience has been that some healthcare providers frequently behave in a paternalistic manner, i.e, I know what’s best for you!  Likewise, the balance between “beneficence” and “non-maleficence” is between doing good and doing no harm.  The decision to prescribe ineffective doses of an opioid or to provide a small number of opioids pills because of concern regarding DEA or Medical Board oversight skirts the line between doing good and doing harm.  The decision appears to be based on protecting the physician from a DEA or medical board that acts to assert its authority and whose actions appear to be arbitrary and capricious.  The criminalization associated with prescribing opioids has impacted appropriate patient care.  Who suffers….our patients.

The establishment of a relationship founded on trust and based on a healthcare provider’s code of ethics and professional standards, creates an important bond between the patient and his/her healthcare provider.  The patient knows that we are acting in their best interests; knows that we are available to them; that through transparency we will share information that may affect their care, including information when things don’t go as planned.  Attorneys frequently try to erode that mutual trust and bond when issues of a poor outcome have arisen.  Patients appreciate being treated as a partner in their healthcare and are less likely to seek retribution when things do not go well.

In reviewing a large and increasing body of literature on the use and misuse of opioids to manage chronic non-malignant pain, there are many principles that may benefit the healthcare provider and patient.  They include but are not limited to: performing a thorough history and physical examination; attempting to identify the etiology of the pain and comorbidities; identifying allergies; identifying all options available to help manage pain, their potential side effects; identifying prior exposure and experience with opioids; identifying potential side effects;  identifying addiction potential (a psychobiologic issue); discussing expectations; creating an opioid contract; referring for a second opinion if necessary; keeping a pain log; and especially, documenting all patient interactions, particularly addressing pain control, functional status and side effects on a regular basis.  Knowing when to transition towards long acting opioids from frequent short acting agents for managing chronic non-malignant pain is important.

I am not being cavalier in recommending that opioids are the answer to managing every patient in pain.  Quite the contrary, I understand the potential for misusing opioids and how diversion has created an atmosphere of fear amongst patients and healthcare providers.  However, clear communications with our patients, following ethical principles in clinical practice, acknowledging our professional oath and that patients are our partners in their healthcare, are critical principles to follow in fostering a healthcare environment that is non-adversarial.