Pain management depends too heavily on narcotics

by Michael Kirsch, MD

First, let me state unequivocally that I am against all varieties of pain, foreign and domestic. Indeed, I wish that we could snuff the varmint out every time and place it surfaces. Pain is a wily opponent that can be difficult to vanquish. In recent years, physicians have been resorting to a ‘shock and awe’ strategy of using excessive force against it.

While this may be sound military strategy, in the medical arena it has led to unintended and predictable consequences. I think that we physicians are pulling the narc trigger too quickly and too often.

It’s easy to advocate for a more parsimonious approach to pain control, when your humble blogger is pain free. Indeed, my own pain threshold cruises at low altitude, and has never been fairly tested. While this may limit my credibility, I maintain as a physician that my profession, including me, needs some narc reform.

When I was in medical training, during the days when my kids insist that I took the pet stegosaurus out for a walk, we prescribed narcotics for serious pain. Of course, all pain is serious, if you are the sufferer. Nevertheless, in those days we prescribed morphine, and its cousins, in specific clinical situations. We prescribed them in patients who were enduring the agony of kidney stones, myocardial infarctions, intestinal obstructions, acute abdomens, traumatic musculoskeletal injury and post-operatively. These medicines, in general, were reserved for acute pain. This bedrock medical practice has not changed.

Additionally, in those days, we physicians were taught to refrain from prescribing narcotics to manage chronic pain, in order to avoid causing medication addiction. Some doctors were also concerned that writing prescriptions for controlled pain medicines would invite scrutiny from medical boards and other oversight institutions. As the medical specialty of Palliative Care developed, physicians were reeducated that narcotic medications had a necessary role in the treatment of chronic pain, particularly in patients who were suffering from a terminal illness. Palliative Care taught us that we had been overly dogmatic and we needed to loosen up.

Another medical specialty, Pain Management, has emerged in recent years that treats patients with all sorts of chronic pain, often without a specific diagnosis. Gastroenterologists, for example, refer patients with unexplained abdominal pain to these specialists, not for diagnosis, but to manage the pain. This is is tough specialty, as the bulk of their practices are chronic pain patients, most of whom have exhausted other therapeutic alternatives. For many of them, these pain doctors are their last best hope.

Enter Morphine Mission Creep. When I was an intern, gazing out the window at flying pterodactyls, physicians didn’t prescribe enough pain medicines. Now, we have more than made up for our prior pharmacologic stinginess by turning the narcotic hose on full blast. Physicians now prescribe addictive and powerful narcotics routinely to patients with a variety of chronic painful conditions, particularly in the hospital.

I witness this regularly on my hospital rounds, and am sure that other physicians can corroborate this observation. Patient come to the emergency room, often already on narcotics, complaining of breakthrough pain. The emergency room physician will then prescribe a stronger agent to be administered intravenously (IV) every 2 or 3 hours. This narc cycle goes on for several days. These folks are so tolerant (‘immune’) to narcotics, that they require high doses to achieve pain relief. Often, these patients will complain that even high doses at frequent intervals are not sufficient. Many of these individuals are truly experiencing pain, although nurses and physicians often observe that some of them seem too comfortable to warrant IV narcotics.

It is now common, for example, to medicate patients with chronic abdominal pain – stomach aches – with IV Dilaudid, a powerful and addictive narcotic. Unlike acute pain, which will terminate, chronic pain lives on. Therefore, if a physician opts to prescribe addictive medicines to these patients, then what is the exit strategy? When we physicians go narc, we create an expectation that the patient’s ongoing condition needs narcotics.Over time, the patient becomes tolerant and addicted to these medicines. In many instances, the narcotic dependence and addiction becomes a much more serious disease than the original illness.

The medical profession needs to pull back from fostering narcotic ‘free love’. We all agree that the enemy is pain. Physicians should remain devoted to our mission to relieve pain and suffering in our patients. In many instances, we have been giving patients the wrong tools for the job. I’m not suggesting we adopt a narcotics moratorium on chronic pain, but that we be more judicious about their use. New specialties and medical expertise in pain management and control have many strategies and techniques that can be safer alternatives to chronic narcotics. We need to learn about them from our colleagues.

When we physicians held back pain medicines decades ago, we were wrong. I don’t think that we have it quite right yet.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • Dr. Nick

    And what are these narcotic sparing regimens we are going to use in hospital? Toradol rarely works for the serious chronic pain patient, and in any case renal dysfunction is common.

  • Kathy

    I just want to point out from your post that it isn’t clear if you understand the difference between addiction and dependence on narcotics.

    And sometimes there is no “exit strategy” for narcotics. Does there have to be one?

  • Erik

    As more and more chronic pain patients show up in ERs, it is often easier and less labor intensive to just give them a few doses of IV dilaudid.

    Then they get admitted and after the third 3 AM page the on call hospitalist says “fine, whatever, IV DIlaudid, just stop paging me already.”

    Hospitals and clinics (read employers) are too obsessed with favorable Press-Ganey scores to worry about appropriate use of medications like antibiotics or narcotics. It’s about having a pleasant stay.

    Eventually tthe health care system will learn how to say no, and stop treating the desire to stay numb with IV narcotics. Until them, all physicians will continue to see patients who abuse narcotics not from black market sources but from the very hospitals and clincs that employ their collegues.

  • PA MD

    This blog and replies is so judgmental and condescending I do not know where to begin. Yes, a small slice of folks develop opioid issues of non-therapeutic desire (“addiction”)….but its a small slice, yet these folks paint all and castigate.

    It is easy to get grizzled and hardened. Its hard but right to still care and reserve callous acts for a tiny group with absolutely clear behavior.

  • Yious

    It cuts both ways. I am just a regular joe reader here that comes here for the stories so I can feel like I understand where the doctors come from.

    I understand there are many, many addiction-wanting people out there but I also have friends who have serious injuries that don’t get the proper pain medicine for their injuries b/c their doctors are so scared of prescribing anything remotely hard.

    Friends with multiple cracked ribs would get little help sleeping or just living with their medicine and would TELL the doctors but get told it was all they could prescribe….one doctor gave my friend (and I hope I say this right) Tylenol with codeine? Is that right? My friend begged that it wasnt working and I was living with him as a roomate and heard him cry all night….doctor wouldnt budge

    And other examples….I feel that the addicts FAR OUT-NUMBER those needing it and not getting it…I understand that….but I still feel for those not getting what they should to live normally

  • Wendi

    I am married to a migraineur. One thing I’ve noticed is that people with chronic, poorly understood pain disorders, like migraines, is that they are often dismissed as exaggerating their pain. Questions such as “have you tried ibuprofen” get asked, frequently, with any visit to a new doctor.

    I submit that such a question is insulting and rude. Why would someone take half a day, at least, off of work, and pay an extra $35 copay to a specialist, if an OTC product was actually working to control the pain? Going to the doctor to discuss chronic pain is not fun. It is not an enjoyable, relaxing experience. has a pain scale created by a blogger that a large number of migraineurs are starting to pick up and use. Migraineurs, especially those with daily chronic migraines, generally don’t complain until they hit pain levels described as “Jesus is coming for me and I am scared”.

    Many realistic chronic migraineurs have given up on having a pain-free life. They want enough medication to maximize their functionality, and this is where pain management docs often lose respect from their patients. If Topamax, or Depakote, or Effexor, or the other “throw this at it and see if it works” medications have side effects that incapacitate the migraineur, then being migraine-free is meaningless. People with daily chronic pain have an entirely different definition of “pain that needs treatment” than the general population. For people who’s pain levels is regularly a 4 or 5 (on a classic 10 scale), it’s just not worth going to get narcotic pain medication until they hit 7+. Otherwise, they’d be in the doc’s office constantly. Every. Single. Day. It’s disheartening for these patients to then go to the doc for exceptional pain, and then be told “since you won’t take this ‘preventative’ medication, you’re noncompliant and we can’t help you”, especially when the ‘preventative’ medication has side effects that affect things like employability.

    I’d like to see just a bit more focus on the goal of pain treatment being ‘making the patient as functional as possible’, rather than simply ‘make the pain stop’. What good is being pain-free when you are so medicated you can’t do any of the activities you can do when you’re having a relatively good day, without the medication?

  • rezmed09

    The problem for many patients I see is that the time spent negotiating and the explaining concerning narcotic amounts and types far exceeds the time spent working on chronic disease management. The result is that patients expectations often end up with the formula (time spent waiting)=(amount of narcotic obtained). Patients no longer want to work on lifestyle changes, they do not want to discuss sleep cycle, exercise, diet issues – they want a pill that will make the pain go away — now. Which solution is easier, more profitable for the providers?

    The floodgates of narcotic use were opened by JCAHO and all the “Doctors don’t treat pain like they should” lectures and media articles. The rivers of narcs poured into our society were fed by Pharma and their profits from OxyContin. The explosion of narcotic use is associated with a higher death rate. It is a matter of time before we wake up and realize that chronic narc patients are worse off than chronic pain patients.

    • Anonymous

      Ditto! Also the pain management specialty is pretty lucrative, so there’s more secondary gain there.

  • Hospitalist

    Wendi – I always ask patients which OTC (or even prescribed) pain medications they have tried. This is for two reasons.

    First, I need to know what you have been taking so I can try something in a different class and/or not overdose you. If you came in with a kidney stone and had tried 2400 mg of ibuprofen, I am going to be careful with anything more than a single dose of ketorolac. I just had a patient in acute renal failure (now resolved) from 3 doses of ketorolac only.

    Second, asking about exacerbating and alleviating factors (including medications) is just part of a good, thorough history and physical. You know, the one that no one seems to think we do anymore.

    So don’t take offense to that question. It’s not meant as an insult – we’re just trying to gather information. I can’t speak for everyone, but I certainly don’t expect that someone with 10/10 pain would get any relief from a few ibuprofen.

    • Wendi

      @Hospitalist – We are very sensitive to wording most of the time. A doctor who asks us WHICH OTC meds we’ve taken, and at what dose, is a joy and a pleasure to deal with. It means he’s taking us seriously, and he’s taking potential drug interactions seriously, and we like that. We like that a lot.

      A physician who asks us “HAVE you tried (ibuprofen/acetominophen/etc)” is asking us an entirely different question. He’s asking a question that assumes we ran straight to the doc at the first sign of a minor tension headache. True, the doctor might only be using a poor choice of words, but it’s an important difference. Even the simplest preface of “I know this is annoying, but I have to ask for the record…” would help avoid a lot of resentment on the part of chronic pain patients.

      Also, I’m assuming from your username that your primary working environment is a hospital, and that you get called in for ER consults occasionally for things like this. That’s a very different environment from a neurologist’s private practice office. In a hospital, I’ll interpret “Have you taken any Motrin or Tylenol?” to mean have I taken any in the last 24-48 hours, for this particular episode. In a doctor’s office, the context is “have you even tried taking regular OTC meds for your ‘severe’ pain?” rather than “OK, you’re complaining of a years-long history of migraines, so let’s run down the list – how much Motrin do you take? How about Tylenol?”

      I do understand that doctors need to be efficient, and there’s a lot of things to cover in as short a time period as possible. It’s why I try to bring in a written list that includes things like “OTC use – ibu 200 mg t.i.d. daily, aceto 500 mg t.i.d. twice a week, naprox NA 200 mg b.i.d. Stomach upset common, has history of H. pylori”. It’s not at all reassuring to have a doctor dismiss that, and ask IF we’ve taken any OTC meds for these “headaches”.

      So, please, be reassured that we’re not painting all doctors with the same brush. I’ve dealt with enough of them to know how wide the variance is on personality and bedside manner. Also, however, my intention here is to illustrate clearly how easy it is for a perfectly pleasant, concerned doctor to wind up facing a patient with chronic pain who’s fearful, anxious, and defensive, and I think it’s something that many doctors may know intellectually, but they tend to overlook it when actually interfacing with the patient.

  • Meg Bressette

    I think there is a disservice done to the patient when you generalize all people on pain medications for chronic pain. I have two herniated cervical discs with nerve entrapment that I wear a pain patch daily to alleviate. I also have percosets prescribed for breakthrough pain (yes it does happen but luckily not often). I have always told my doctors that I don’t need the pain to be completely gone, just to be at a level that I can tolerate which for me is about a 4 on the pain scale. I like to function. I have had surgeries and intractable migraines that have required intervention. Doctors continually assume that because I am on pain medications that I can handle large doses of pain medications such as morphine. I now have to vigilant in telling them not to give me stronger pain medications such as morphine after surgery. Pain medications are like any other medication – they need to used with diligence and understanding their limitations. When they do work as the pain patch did for me after a year of other treatments it can change a patients life for the better.

  • Diana Lee

    I live with chronic migraines, and I’ve come to learn over the years that narcotics are inadequate for management of chronic pain. Science supports this idea, too. We now know that narcotics make your body more sensitive to pain and take away its ability to produce endorphins. Behavioral pain management is truly the only logical way to handle chronic pain management. It teaches patients the skills to cope with their pain and learn tricks for minimizing it. Pain is most certainly undertreated, but I think the main reason for this is not that pain is not taken seriously (though this is a huge problem), but that too many professionals don’t know how to help their patients.

  • Russell Belcher

    Out of all these post there are 3 words I did not see even one time. Quality of life. If you ask anyone who suffers with chronic pain what those words mean they can write you a book.
    I broke my back in the Army 35 years ago, 15 years or a little better ago the fusion cracked and I was in the hospital 3 weeks. I continued to work in excruciating pain for the next 5 years then in 2000 ended up in the hospital again, since that time I have been disabled.
    Some of these so called pain interventions are just plain poop. They do not help, I have had enough steroids pumped in my spine and given to me orally to grease an automobile. You know the whole time the Veterans Administration was pumping those things in me they were also blowing smoke up my butt telling me there were no long term side effects from all those steroids, LOL. I won’t go in to the list of secondary problems I have now from all of those. You ever looked at your bill and seen how much those wonder injections cost your insurance company if your blessed enough to have insurance. I like the doctor even better that tell you I’ll give you your prescriptions after you get your series of injections. This does not apply to all doctors those of you out there know who it applies to.
    Another thing I noticed here is doctors using the term Narcotics, People envision police cars with cars pulled over and a trunk load of stash worth upteen million dollars according to the police report. For God’s sake you are and educated doctor they are opiates or opioids. People like you are the ones that give it that stigma of being something bad right off the bat.
    I’m not bragging here because the Lord only knows my IQ is not near as high as a lot of you doctors are by any means. I will tell you this though I would pit my knowledge about pain against 85% of you because I have studied it and I live it 24 hours a day 7 days a week because one of the secondary symptoms is Intractable pain syndrome.
    May God Bless you people who suffer from Chronic pain.

  • Ms Margie

    Chronic pain is real. It is life altering. It can create a strain on relationships and result in the loss of jobs. It can cause some poor souls to contemplate taking their own lives. Sadly, some of them actually follow through, God bless them.

    Even though there are some in the medical community who wish to dispute and condemn it, for the vast majority of chronic pain patients the prescribing of opiate/opioid medications by competent and caring physicians, is the only thing that gives them back even a portion of their former quality of life.

    Contrary to what the “sweeps week” talk shows and network news “special” reports would like the public to believe, we are not all secret vicodin addicted suburban soccer moms, or deadbeat dads who spend the mortgage money on their oxycontin habit, or the black sheep cousin who’s been in rehab six times.

    We are mothers and fathers and sons and daughters; sisters and brothers. We’re your neighbor, your fellow congregant at church, your teacher and yes, maybe even your doctor. We don’t take opiates to “get high”. We take them so that we can make dinner, sit in a chair long enough to read to our children at bedtime, go to work to support our families and a multitude of other boring, mundane, everyday activities that people without pain take for granted.

    Prescribing opiates for chronic pain is rapidly becoming a dangerous means of practicing medicine. The DEA is conducting “witch hunts”, and harrassing physicians who are doing nothing more than attempting to honor the oath to “first do no harm”, by providing quality, humane care for their patients.

    Passing judgement, without ever having lived a single day in a body ravaged by constant pain, is not only unfair, It’s cruel. With all due respect, physician, heal thyself.

  • Girl Gone Healthy

    Therein lies the problem. Chronic pain is such an affecting condition that without pain relieving medication, it’s a serious problem. Hopefully there can be alternatives to pain medication, and a solution to this dilemma.

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