The bias behind narcotic prescribing

Narcotic pain medication prescribing is an issue heavily laden with emotion these days. I have observed that most doctors tend to fall on one side of a spectrum bordered by these two extremes:

“Undertreated pain is worse than addiction.”

On one end is the doctor who is deeply, morally troubled by patients in pain. This doctor is not unaware of the risk of addiction but is willing to risk being taken advantage of by a wily narcotic seeker rather than leave pain untreated. This doctor knows that undertreated pain can tremendously decrease his/her patients’ quality of life. He/she feels that relieving suffering is one of the most important responsibilities of a physician.

“Addiction is worse than undertreated pain.”

On the other end is the doctor who is deeply, morally troubled by the possibility that he/she may contribute to someone’s narcotic addiction. This doctor is not indifferent to pain but is willing to risk undertreating pain rather than inadvertently create an addict. This doctor knows that every single narcotic addict gets their ongoing pill supply, directly or indirectly, from a physician’s prescription pad. He/she feels that preventing the misuse of these dangerous medications is one of the most important responsibilities of a physician.

Most docs naturally lean toward one end of that spectrum; they are more naturally inclined to either worry about pain or worry about addiction. I’m not trying to suggest that one way of thinking is superior to the other, as pain and addiction are, of course, both terrible problems.

Doctors are merely imperfect human beings, and we will not always make the right decision about prescribing narcotics. At times, we will not treat pain that we probably should, and, at times, we will prescribe narcotics for someone we probably shouldn’t. Which end of the spectrum we fall on might just determine which of those two outcomes is more likely for our own patients.

I lean more toward the “pain is bad” end, myself. I hate to see people in pain, but, like most family docs, I’ve also been burned a few times by clever narcotic seekers. I have to constantly remind myself to remain vigilant in my efforts to detect narcotic abuse, as my natural inclination is to trust people until they’ve proven themselves untrustworthy.

I’ve shared these observations with the residents I work with, and they can usually describe which side of the spectrum they each prefer. This self-awareness is important for us as docs; by recognizing our biases, we can consciously decide how much we will allow them to influence our decisions.

Better defining the values behind physician behavior may be a necessary step to improving care for both untreated pain and narcotic addiction.

Jennifer Middleton is a family physician who blogs at The Singing Pen of Doctor Jen.

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  • http://www.bechronicallywell.com/ Tina Tarbox

    Great article! I’ve found that my clients typically encounter one end of the spectrum or the other, just as you detailed above. I also try to be very careful when I’m working with individuals who suffer from chronic pain. My personal experience, as someone who has had rheumatoid arthritis since I was a young child, is different from that of many clients I encounter. I learned from an early age to “tune out” certain types of pain and have had a great quality of life without narcotics. I do believe it’s tougher for adults who are facing chronic pain and who have never dealt with it before. I appreciate your candor regarding bias and physician self-awareness.

  • boucains

    Trust but verify = Prescribe but monitor. I am a chronic pain patient who has stayed on
    the same dose of morphine for more than 6 years. I worked HARD to establish
    trust with my new PCP after moving to another state. Why is keeping trust with your doctor
    different from the blood tests for cumadin patients, etc.? Just as each human has a slightly different
    genetic code, not all pain relief methods work for all patients. Each method requires a different kind of
    effort. If a patient is in enough pain
    to *require* narcotics, then they should be happy to take reasonable steps to
    relieve their doctor of the worry that abuse is occurring.

    I believe that Dr. Middleton is using “addiction”
    in the proper way. Some do not. Patients
    who take narcotics will become physically dependent on them. That is VERY different from being addicted. In the same way, legally prescribed and used
    narcotics are medications, not drugs. Please
    do your part to help chronic pain patients lead a normal life without the
    stigma of being “addicted to drugs”.

    I believe that Dr. Middleton is using “addiction”
    in the proper way. Some do not. Patients
    who take narcotics will become physically dependent on them. That is VERY different from being addicted. In the same way, legally prescribed and used
    narcotics are medications, not drugs. Please
    do your part to help chronic pain patients lead a normal life without the
    stigma of being “addicted to drugs”.

    • NewMexicoRam

      Just as the loudmouth bully in the classroom causes the teacher to crack down on everyone, so it goes with the narcotic abuser in a medical practice. Everyone suffers.

  • http://twitter.com/bostongal1641 bostonmeg

    Good article that discusses the issue without putting the label of “addict” on all who use narcotic pain medications.

    It took over a year to find a combination that relieves my pain and lowers that level for a 4 on scale. That is low enough for me to ignore or go on with my day without feeling like I want to pull my skin off. Not all chronic pain is pain that you can ignore – I found that out the hard way and I thank god every day that I have a 20 yr relationship with my PC Dr who manages my medications. I work really hard to make sure that I never put him in an uncomfortable situation regarding my pain medication useage.

    I think it is awful that people will use & lie to physicians who just want to help patients with pain so they can get drugs. It makes the physicians less trusting and also makes it harder on those of us who legitimately need this medication.

  • http://www.facebook.com/carol.levy.336 Carol Levy

    The DEA has forced doctors to see those with chronic pain as potential felons first and patients second. To require patients to sign ‘opiod contracts’ that require among other things, permission for ‘random urine screenings’ presupposes illegal activity.
    It would be nice if we were seen as patients first: “trust people until they’ve proven themselves untrustworthy” as Dr. Middleton writes, and then, if and when they give reason for suspicion, treat them as untrustworthy.
    Carol Levy
    author, A PAINED LIFE a chronic pain journey

  • Lisa Glavish

    Good article! I’ve been on and off norco for over two years since I was diagnosed with RA. What I found out eventually is that if the pain is bad I have to not only get it under control, but KEEP it under control. During these times I do build a tolerance to this drug, and I do have to increase the dose…. but when I’m doing well it has never been a problem just to taper down, then off, the pain meds. What made it bad was when I would wait until the pain became quite unbearable and then take the meds- I found myself preoccupied with pain, hating life, and thinking ‘when can I take another pill to feel better?’
    These days, if I’m in pain, I take the meds on a fairly regular schedule- every 3-4 hours. When I start to improve I usually find out because I won’t wake up from my pain and have to take another dose. Then I’ll taper to 6-8 hours, then twice a day, then once a day then done. It usually takes just a few days.
    What I don’t want to do, is have to worry about not having enough meds to get me through a bad patch on a weekend or when I’m out of town. It is a good feeling that my doctor trusts my judgement- if anything, it’s made me a more responsible patient.

  • kr

    this article is very personal for me, as an RN and a long-distance caregiver for a brother with significant chronic pain and many diseases.

    He was doing fairly well on prescribed oral morphine (extended release and short-acting) for 5 years. There were times when he had a little more month left than pills, and he “supplemented” with buying street pills. BUT, he was functioning fairly well, living on his own (within limits of his disease.) In general, he scheduled out his pain meds quite well. Due to other conditions, he could not take ibuprofen, acetaminophen, gabapentin; and pregabalin had awful side effects.

    In late Fall 2011, his doc decided he would no longer prescribe the MS, and prescribed a relatively speedy withdrawal schedule. Since that time, my brother spiraled downward; he drank more and bought more meds on the street. He was in very bad pain, and attempted suicide.

    Over the next few months, he was in the hospital much more, and then developed other conditions: infections, bedsores, etc. From Feb. 2012 to mid July 2012, he was in the hospital about 90% of the time — would go home, and be admitted again via ER within 36-72 hrs.

    I argued with his docs repeatedly, asking what the answer was for his pain, when he could not take alternative meds (they were all tried.) The docs had no answer. They offered the pain clinic, which he’d gone thru other times. No matter how much Positive Thinking, Re-imagining, spend-time-with-friends, and “focus-on-your-happy-place” one can try, physical pain is still physical pain.

    He just died Sunday, and while the direct causes cannot be confirmed, I firmly believe he would not be dead if his pain was under proper control. His last 9 months were miserable, whereas before the MS was withdrawn, his pain was fairly well-controlled.

    i don’t know the answer. I know docs are under pressure to be stingy with opioids. But how can we deal with the patient who really has long-term pain, whose med choices are limited?

  • http://www.facebook.com/casey.hibbs.1 Casey Hibbs

    OH I HAVE NO OPION BUT TO TAKE THE DAME PERCOCET EVERY TIME I FOUND SOMETHING THAT WORK AND I HAVE HAD 10 SURGERIES 5 ON MY SPINE OPEN BACK I WAS FINE FOR YEARS BUT NOW I CAN BEARLY WALK PERCOCET WORK WHEN THE PAIN STOPS I AM HAPPY IVING WHAT LIFE I HAVE LEFT SO GIVE ME THE CHOICE WHETHER ADDITION OR HAVING A COMFORTABLE FUN LIFE I AM 50 YRS OLD I CAN BEARLY WALK I DID EVERY THING THEY SAID AND MORE IT WAS NOT TILL 4 YEARS AFTER I HAD MY SECOND ROUND BACK TO BNACK ON MY SPINE THAT IT GAVE ME 3 YEARS IT TOOK MY LIFE AWAY AND NO MATTER WHAT I KEPT FITTING BACK WITH EVERYTHING I HAD AND I STILL BEARLY GET OUT OF BED I USE TO BE FUN SO I WILL TAKE THE GOD DAM ADDITION AND HAVE A LIFE EVERYTHING HAS A SIDE EFFECT SO HOW IS THAT ANY DIFFERENT AND ANY WAY IF U USE IF FOR PAIN THEY U WILL BE FINE NJ SUCKS THEY HAVE THE DR HANDS TIED BUT IF THEY WLD OPEN THEIR MOUTHS I WLD NOT BE WITHOUT A PAIN MGMNT DR SO ASS HOLE HOW DO U WALK DO U HAVE FUN WITH YOUR KIDS DO U HAVE SEX SORRY BUT THIS IS A TOUCHY SUBJECT FOR ME I NEVER EVEN TOOK A TYLENOL

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