Pain requires doctors to accept false positives on drug seeking behavior

Patients requiring controlled substances to manage their pain have always been controversial to treat.

Every time the subject is broached on this blog, the comments inevitably becomes a contentious discussion of “drug seeking behavior” versus treating legitimate pain.

It’s a problem that doctors nationwide grapple with every day, and is addressed in a recent essay from the New York Times.

Michael Kahn is a Boston psychiatrist, who recently asked residents how they would approach a patient who had asked for Xanax, a benzodiazepine often used to treat anxiety.

In the end, Dr. Kahn notes that,

the prevailing attitude was one of “they’ll have to pry that pill from my cold dead hands.” It made me wonder whether these budding psychiatrists might be working too hard to avoid being hoodwinked.

He then compares screening patients for drug seeking behavior with tests from other medical fields:

Surgeons are fooled when they open an acutely painful abdomen only to find a normal appendix: in the days before CT scans, it was said that if that didn’t happen once in a while, you weren’t operating often enough. When in doubt, it was safer (and wiser) to operate than to risk a rupture and peritonitis, even if the diagnosis was “wrong.” Here was an error that wasn’t an error, but rather a predictable side effect of balancing known risks with imperfect information.

Applying that to pain management, he suggests accepting a degree of false positives instead of missing patients with true pain: “I’d rather be taken for a sucker once in a while than know that my suspicion had denied someone legitimate help.”

That’s certainly the ideal, but the federal government isn’t helping matters much.

Recent high-profile crackdowns of more liberally prescribing physicians have scared doctors into a bunker-like mentality. Until there is better clarity from both law enforcement and pain specialists as to what constitutes appropriate pain management prescribing, it’s likely that patients in true pain will continue to suffer.

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