Why doctors treat patients as drug addicts

Why doctors treat patients as drug addicts

Fact: Doctors want to help people.

Fact: Some people take advantage of doctors.

A doctor in Oregon shares this case:

I had an old man with cancer. He kept complaining of pain as I was increasing his opiate pain medication, Oxycontin. I was at, I forget, about 40mg four times a day or some fairly substantial dose. I ran a urine drug test. Negative for oxycodone, which was what I was giving him. Turns out his caregiver, who was the old man’s son, by the way, was stealing every single narcotic pill I was prescribing and selling it. Oxycontin is a dollar a mg on the street. So, the scumbag son, stealing his cancer-ridden father’s pain medicines, was clearing $40 a pill, 4 times daily, 365 days a year … 40 x 4 x 365 = $58,400 … Potential of nearly 60 grand a year doing this to his father. And yes, I called the police and adult protective services.

Fact: Oregon is #1 in the nation for non-medical abuse of prescription painkillers.

Oregon is a progressive state. We’ve been on the forefront of compassionate use of pain medication. We were the first state to decriminalize marijuana and among the first to allow its use for medical purposes. Oregon was the first to legalize physician-assisted suicide and to require a prescription for pseudoephedrine to decrease meth production.

“But why are we #1 for abuse of painkillers?” I asked at a mandatory course I attended on the safe use of opioid pain medication.

I learned that being so compassionate with prescription painkillers can backfire. Sometimes a doctor’s compassion is met by indifference, manipulation, and lies. After these experiences, even the most caring doctors start to distrust patients.

Leila, a patient, shares:

I was brought into the ER by ambulance after a car accident. I had been left on the backboard for five hours, and I [previously] had major back surgery. I was in so much back pain that I was crying. I was only treated for whiplash. The next day, as I was screaming in pain, my husband took me back to the ER, where I was treated as a drug addict and told I couldn’t get anything for my pain.

Fact: Some patients need pain medication.

Fact: The U.S. is 4.6% of the world’s population, yet we consume 80% of opioid painkillers. And we’re still in pain.

Lots of Leilas receive inadequate pain therapy. While lots of scam artists make a living off prescription painkillers.

Anyone have a quick and easy solution?

Pamela Wible pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Pet Goats and Pap Smears. Watch her TEDx talk, How to Get Naked with Your Doctor

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  • MatthewMArnold

    There’s a number of products coming to market, including Proteus’ ingestible sensor and Ai Cure’s facial recognition technology, that aim to provide verification that patients have taken their meds as directed. Pain meds are, obviously, top of mind for them.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Interesting . . ..

      How is that better than doing a urine drug screen?

      • RenegadeRN

        Ah you beat me to it!
        Most patients who require opiates have need of labs drawn, what about adding an opiate screen ,at random, on all prescribed to validate they are the actual recipients? Urine is too easily tampered with if a screen is anticipated.

        • http://www.idealmedicalcare.org PamelaWibleMD

          Anyone feel more like a police officer than a doctor?

          • guest

            Actually during the time I was involved with pain patients, I felt more like a prostitute.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Tragic

  • Lisa

    Pain may be unavoidable, but it still should be treated.

    I’ve had significant amounts of pain at times, post surgery or injury and have needed pain medication to sleep, so I welcomed that side effect of the pain medication. Are you suggesting that pain shouldn’t have been treated, that I should have been denied pain medication because I might be a drug addict?

    • http://www.idealmedicalcare.org PamelaWibleMD

      I am suggesting that some docs have been so burned by bad experiences with manipulative patients who have lied to them that they may not be inclined to prescribe opioids to patients who may have “real” pain. In these cases you may be denied pain medication because you may be considered a “drug addict.”

      • Lisa

        Pamela, my rhetorical question was really directed at Gerdoc and his suggestion that pain maybe unavoidable, wondering if that should be a reason not to treat pain.

        I guess I am lucky that none of my doctors have assumed I am a drug addict; After every surgery or serious injury, I’ve been offered adequate paid medication. I’ve also been given pretty good advice on ways to control pain without medication.

        • http://www.doccallum.com Martina P Callum MD

          That’s a big part of the solution…continunity of care..it sounds like you were going to the same doctors and not doctor shopping.

          • Lisa

            Yes, I was seeing the same doctors, but the people who helped me with dealing my chronic pain have been physical therapists and occupational therapists. What my doctors have provided are referrals to these therapists and approvals for compression garments which are used to treat lymphedema. I have had to request these referrals as my doctors’ first inclination is to pull out their prescription pad.

      • http://www.doccallum.com Martina P Callum MD

        Thisis where the pharmacy boards can make a difference, We have all at some point in time been burned by a patient we were trying to help but we can’t make everybody else pay the price.

    • PoliticallyIncorrectMD

      I don’t think Gerdoc is suggesting you should’t have been treated with pain medications. I think his point is, there are limitations to what opioids can do (safely). Therefore, achieving completely pain free state in some conditions may not be realistic and escalating doses of opioids should not be prescribed if they don’t work.

  • NewMexicoRam

    I thought New Mexico was #1. Maybe it’s “was.” Our state has implimented a fairly aggressive medication abuse prevention program, so maybe it’s working.

  • ninguem

    What happened Pamela, did you run out of cardboard?

    • http://www.idealmedicalcare.org PamelaWibleMD

      i just loved your real life story. Of course, I’d enjoy seeing you with a piece of cardboard if you would reveal yourself.

      • ninguem

        What’s really so special about that story?

        Surely you’ve seen the same.

        Both drug diversion and elder abuse, unfortunately, happen all the time. I got a twofer with this case.

        • http://www.idealmedicalcare.org PamelaWibleMD

          I have not seen anything like this!

          • ninguem

            ……preparing bill of sale for Brooklyn Bridge……..

            Your last name, one “B” or two?

  • Deceased MD

    I think our very own Dr. Ninguem had that fun case with Adult Protective services. I don’t envy him. Personally I don’t think there are good answers. Often medicine is less than competent at diagnosing pain as it is of course just the symptom. When it comes to obvious need for narcotics such as after a surgery or cancer, we really can’t always control what pts will do. The elderly man with cancer, unless he was demented, let his son take advantage of him and i imagine this was going on for a very long time, even before the elderly man got ill. And it was not news to him that his son was an addict.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Oh wow! That sounds like science fiction . . fun!

  • Lisa

    Ah, I see. At least pain medication lets you sleep.
    Sigh. . .

  • guest

    56% is still a pretty horrifying number, though.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Oh . . .I learned that “fact” from a safe use of opioids CME that I was mandated to take by the state of Oregon. Sorry if I got it wrong . . .

    • ninguem

      That “80% or 90% of world opiate production” factoid probably refers to oxycodone and/or hydrocodone, which we may well use disproportionately in the USA. Morphine and other opiates may be used elsewhere.

      Data can be found here:
      http://www.painpolicy.wisc.edu/home

      • Payne Hertz

        Read the site you posted. The data are based on morphine and “morphine equivalents” which are determined using some formula for equianalgesic dosing. They stopped using morphine alone as the standard for determining pain treatment availability years ago.

  • Suzi Q 38

    I don’t know what the answer is.
    Just do what you want to do. Just like the song.
    I take pain meds, but they are not opiods.
    Right now I take a generic tricyclic antidepressant in a low dosage (25 mg). I am fortunate that it works for now. After my c spine surgery, they gave me Norco. I used it for about 3-4 days, then switched to Tylenol, Advil, or Aspirin on alternating days. The OTC drugs did not work well.

    I was in so much pain that I could not sleep or straighten up when I wanted to stand. I refused the Norco and Vicodin because of the negative talk about the opiods. I told my doctor that I used to sell Sinequan (doxipen)…could I give it a try? Instead, she prescribed Elavil, and I gained 15 pounds and ate food and candy 24/7. I expecially craved sweets and carbs. My thyroid became sluggish.
    I asked for a different med, so now I am on Nortriptyline. Maybe it is the placebo effect for me, and I just think it is better. Time will tell.
    Anyway, as far as working for my pain and giving me the sleep that I need, I am soooo happy.
    I just hope I can quit gaining weight. Now THAT is depressing.

    My point is that there are other drugs that work.
    there is a lot between the OTC’s and the Opiods.

    If I went in to my doctor and asked for Norco, I would expect to be scrutinized too.

    There must be other drugs.

  • guest

    Personally, having spent three years treating patients who were addicted to opiate pain medications, I am all for letting people treat their own pain. There will be a huge public outcry when mortality rates skyrocket, as they inevitably will, but at least physicians won’t have to be caught in the middle of it.

  • RenegadeRN

    Not meant to sound that way at all… Guess my time spent working chemical dependency/ psych has changed my perception of what’s invasive.

    Opiates are necessary to pain relief, absolutely!
    We also have a huge addict population, I have had patients, 20 year olds!- overdose a week after leaving rehab! You see enough of it and you want to do everything possible to prevent such tragedy.
    That IS the gist of this article, correct? To ensure the patient in pain gets relief with out enabling the addict?
    Obviously not in the person with an acute issue, who requires one script. The example used is very sad for the man in pain and in my experience, far too common.

    • RenegadeRN

      My comment to Pamela was really more of a knee jerk , thinking out loud response.
      Make no mistake, I do not consider every person who needs opiates an addict till proven otherwise, and do not want to see people in pain denied relief!

      • http://www.idealmedicalcare.org PamelaWibleMD

        Most if not all of us trying our best to help patients without enabling an overdose or drug diversion.

        To the honest patient this is eye-opening. How other patients live . . . and lie . . .

        • DoubtfulGuest

          What is the honest patient’s responsibility in this whole mess? To try to understand doctors’ point of view? To try to communicate well? To prove their honesty?

          What is the relative moral position of an honest person who 1) requests pain treatment, compared with one who 2) requests some other form of medical care, compared with 3) a non-patient (i.e. a regular honest person who does not request health care resources)?

          • http://www.idealmedicalcare.org PamelaWibleMD

            Honest patients responsibility is to develop a long-term relationship with one doctor. Since it is a relationship, it is best to understand the doctor’s vantage point. Clear, honest, concise communication is favored as is being prepared, following office policies, creating a joint plan of action.

            I’d say the moral position of all should be similar. Bu I may not be understanding your question.

          • DoubtfulGuest

            I would hope it is similar, yes. Thank you.

            My own bad experiences are from doctors’ assumptions unrelated to drug-seeking. I’ve noticed a pattern of patients being treated as morally weak/suspect for requesting any kind of care (except when it’s glaringly obvious that care is needed e.g. re-attach a missing limb).

            True, patients are requesting some share of resources from a limited pool of resources. We should be aware of that, respect that, and try not to take more than we really need. But it seems like many doctors interpret patients’ ignorance about this as a moral failing. We should try to learn. A lot is kept hidden from us, which makes this difficult.

            Regarding pain treatment, Mental Patient made a good point about many patients knowing little to nothing about what they’re getting into with pain drugs. My experience also falls into this camp. We may not be in a great position (say, post-surgery) to ask what is this medication? What is the potential for dependency? How long is typical to need this drug if my recovery follows a “normal” course? When might it be smart to taper off this medication and try NSAIDs or something else? At what point will you start giving me the side-eye?

            I know almost nothing about chronic pain treatment, and I realize everyone is different. I just wanted to point out what seems like a collision between moral assumptions/bias and an information gap in many cases.

          • sparklingsoul

            I have a long-term relationship with my primary care physician, but he routinely outsources me to specialists. That means that I have several doctors treating me. It’s almost impossible to have one doctor treat everything these days.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yes. This IS the gist of the article. How to get the right meds to the right person. It’s not as easy as it looks to an outsider. Follow and ER doc for a day. or The renegadeRN through a chemical dependency unit.

      • Payne Hertz

        Try going to a chronic pain support group, or following an addict for a day. Then ask yourself whether this system is helping or hurting people.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Continuity is key. Lot less frustration in a long term relationship.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Conclusion jumping is a coping mechanism for compassion fatigue.

    • http://www.idealmedicalcare.org PamelaWibleMD

      . . .as in . . . easier to blame the patient suffering for his own predicament or assume that he is being deceptive so that the doctor/nurse/caregiver with compassion fatigue can opt out of caring.

      Yes. This does happen. Commonly.

      • Patient Kit

        Kit holding up a sign that says: :-(((((((((((((((

  • http://www.idealmedicalcare.org PamelaWibleMD

    Oh . . . i do not envy you. ER is a tough job.

    Given that you hate that aspect of your job more than any other, what is your favorite part of your job? The part that keeps you excited to start your next shift . . .

    Curious . .

    • RuralEMdoc

      ER is exciting and rewarding. Every shift is different.

      The thing I love the most is when you actually have the opportunity to intervene and make a difference. Whether that means early intervention in a septic patient or assuring a worried parent that their toddler’s fever is nothing serious, each day is an adventure.

  • http://www.idealmedicalcare.org PamelaWibleMD

    So patients in Portugal choose their own blood pressure meds OTC right next to the hemorrhoid creams?

    • Angela Reuss

      I would hope not.

      • ninguem

        I agree with Angela. You want to put antihypertensives right next to hemorrhoid meds in a Portuguese store?

        I used to practice in East Providence, and I can assure you, nothing good can come from this.

        “Yes Mr. Fernandes I agree. The medicine is not helping your blood pressure, and you’re right, those suppositories taste terrible.”

        • FEDUP MD

          Ah, yes, the “dumb Portagee” jokes.
          No Polish people to pick on?

          • ninguem

            Ai corisco

          • RenegadeRN

            Jak se mas? Ha ha!

    • ninguem

      Not only that, but about twelve years ago, the Portuguese invented a way to perform mammography by satellite, thus eliminating the need to travel to a mammography center.

      From the Diário de Notícias
      http://www.dn.pt/inicio/portugal/interior.aspx?content_id=1649963&seccao=Norte

      Or, if you must insist on English, here’s coverage from the London Telegraph.
      http://www.telegraph.co.uk/news/1398685/Voyeur-gets-women-to-bare-breasts-for-satellite.html

      Or the Portugal News
      http://www.theportugalnews.com/news/view/658-27

      I’ve been trying to bring these advanced techniques to the United States, but I find it hard to recruit volunteers.

      Maybe I should try the Oregon Country Fair.

      • Deceased MD

        Brilliant. May bring HC costs down.

    • Payne Hertz

      No. What Portugal did was decriminalize street drugs, meaning that these drugs are still illegal but possession of small amounts of these drugs will usually not be prosecuted. The results have been overwhelmingly positive and suggest that full legalization is a desirable goal.

      http://www.cato.org/publications/white-paper/drug-decriminalization-portugal-lessons-creating-fair-successful-drug-policies

      I strongly suggest reading the attached white paper by Glenn Greenwald for more details.

  • Lisa

    I am sure you are right that suspicions about addiction are more common with chronic pain. I do have chronic pain issues after a bilateral mastectomy- the thing is that opiates are useless for this pain as it is neurological. I could get scripts for lyrica or gabapentin, but I don’t like their side effects either. So far what has worked best is stretching and treatment for lymphedema. I am not 100% convinced I have lymphedema, but treating it does help my pain.

    • sundance1984

      Thank you for your post. In one of those nasty ironies I am a pain management and palliative care specialist nurse manager. I also suffer from severe chronic neuropathic pain after two spinal surgeries occasioned by my catching a leukemia patient who experienced a transfusion reaction in Jan 1996 on a Sunday afternoon while I was caring for him and he bolted over the bedrails. I slid my body under his. It took another 10 years for the full effects to be known, then repaired — for the FIRST surgery.

      I’ve advocated long and hard for patient access to the medications necessary for symptom mgmt, organizing the first ever Pain Management Summit in CT on March 31, 2003, which brought all the “stake holders” (MDs, RNs, and Pharmacists) with their respective state and Federal overseers.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Do you generally have good communication with your doctor?

    FYI: You might want to start the conversation with, “I was thinking Celebrex may help my pain.” and continue with, “Do you have any other ideas? I prefer not to use narcotics.” This avoids the knee-jerk reaction on part of the doctor to consider you an opioid seeker.

  • PoliticallyIncorrectMD

    Since you are so fascinated with numbers – Gallup reveals 18% of Americans (1 in 5) think the sun revolves around the earth. Who needs doctors? Let patients treat themselves!

    I also assume, since you are advocating for letting people treat their own pain, you would be ok with them treating their own overdoses as well … or would you then gracefully allow those greedy unsafe and incompetent doctors to take over ?

  • DoubtfulGuest

    1. Any time I misjudge another person, I’d certainly hope others would understand external pressures on me that contributed to the misjudgment. I could definitely see wanting to explain those reasons and discuss them.

    2. I’d also ask, how can I get better at reading people in the time I have? What is my personal responsibility in these situations?

    I wonder what doctors feel and think about that second part, in reference to themselves?

    • Payne Hertz

      If someone assigned you the role of trying to distinguish criminals from innocent people based on nothing but behavioral cues, the way they dress, their knowledge of medications or other meaningless factors, would you feel comfortable doing so? What if the people identified as criminals, rightly or wrongly, were sentenced to be tortured for years?

      I suspect the answer is “no.”

      Now ask yourself why so many doctors are willing to play this exact game with regard to distinguishing people with pain from alleged addicts, and why they are so prone to falsely identifying people with pain as addicts, even when the consequences of guessing wrong are certain torture, the destruction of the patient’s life and even death.

      • PoliticallyIncorrectMD

        Most of the physicians are NOT “willing to play this exact game”. In fact , they would gladly avoid participating…except no one else is vilonteering and they are reluctantly forced to do it. In turn, they are blamed for both – inadequately treating people with real pain and overprescribing to people who do not need it.

        • ninguem

          In Oregon, we had a doc investigated by the Board for overprescribing……..when the Board’s attitude was that the doctors were too free with narcotics…….and, years later, for underprescribing……..when the “fifth vital sign” thing was in vogue.

          • Payne Hertz

            “Overprescribing” tends to be a euphemism for drug dealing. In my community a doctor who was a notorious drug dealer, selling scripts from his car no less, got hauled before the medical board after he killed two different patients. In reviewing this case they also reviewed his prescribing record, and discovered he had a habit of prescribing massive doses of narcotics of different types just days apart from each other to select individuals, an obvious red flag for drug dealing.

            The board correctly noted that giving a patient 24 Lortabs a day put the patient at risk of injury or death from acetaminophen, though the narcotic portion was not excessive (12g of acetaminophen is half the lethal dose and 4 times the maximum daily dose). They completely and almost comically danced around the whole issue of his obvious drug dealing and instead focused on that Lortab dose and the two deaths he caused as well as other patients he injured.

            His piunishment? He lost his license for 6 months and was banned from practicing medicine in that county. He is still practising medicine today though I hope he at least got himself a new car to sell scripts from.

            The reaction from other doctors in this area was swift. They dropped their chronic pain patients like hot potatoes and many committed suicide as a result. Even though everyone knew he was a drug dealer, they preferred to adopt the “overprescribing” meme and see him as a victim of the board, rather than a criminal. The board had in fact given him a pass.

            Less than a handful of doctors have ever been successfully sued for denying pain treatment, and doctors are not required to write pain meds to people they don’t want to, so I find the likelihood that a medical board would grill a doctor over this to be very slight.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Yep. No win situation. There are likely no simple answers. Human psychology is far too complex to get a handle on in a 15-minute visit. At least for me. So family medicine fits me well.

        • DoubtfulGuest

          I’m not blaming anyone for anything. I just get concerned that “Doctors get blamed for a lot of stuff they shouldn’t and we need to fix that” *appears* to easily turn into “Everything doctors do is okay because they went into it with the calling to help people”. I’m not sure that’s what’s happening, so I was hoping to understand better.

          • PoliticallyIncorrectMD

            Sorry, the comment was made for Payne Hertz. I’ll repost

          • DoubtfulGuest

            You posted correctly the first time. I was merely attempting to join the conversation. :) I really want to understand how doctors think.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Aha! I’ve been studying physician psychology for 46 years. Both parents are docs. An interesting crowd.

          • PoliticallyIncorrectMD

            I see… I think most of the doctors are there to help people and I doubt there is an organized conspiracy to abuse or take advantage of patients (at least I am not aware and not being part of it). At the same time, I don’t think the doctors are infallible. They are just regular people trying to make our imperfect world a little better.

          • DoubtfulGuest

            I agree that there’s no conspiracy. I just get jumpy every time I see statements like “Sadly, many innocent patients suffer due to the actions of a few bad apples”.

            There never seems to be any plan for doctors to address their personal biases. Like “I see now that you are not a drug addict. I misjudged you because of your vibrant purple Manic Panic hair dye. That has nothing to do with your behavior or your medical problem. I apologize.”

            I realize it’s very hard for doctors to do this. You all get blamed for many things that you shouldn’t. In many cases other people (lawyers, administrators, insurance people) are the real problem and patients should try to see that. I don’t know how to fix this. It just scares me, not to see the same self-reflection from doctors that I’d expect from anyone else.

          • http://www.idealmedicalcare.org PamelaWibleMD

            Hard to have time for self-reflection when assembly-line medicine keeps most docs in survival mode. If given the time to care, more docs would have time to care.

            Empathy burnout = when doctors stop caring because they are exhausted. In primary care, empathy burnout happens after seeing approximately 10-12 patients. Most docs see over 28 patients per day.

            Take-home message: If your medical condition requires a does of compassion, please make an early morning appointment.

          • DoubtfulGuest

            Do we actually move the ethics bar for doctors then? Or maintain the ethical standards and try to solve the problems they face, simultaneously?

            “Take-home message: If your medical condition requires a does of compassion, please make an early morning appointment.”

            Is this to me, or…? It doesn’t seem to fit what I was saying?

      • DoubtfulGuest

        Nope, wouldn’t be comfortable. I’d prefer not to be in a position of that much power over anyone else.

        • Payne Hertz

          Thanks for your answer, it is what i would expect any moral person to feel.

        • PoliticallyIncorrectMD

          Many nobel professions (physicians, police and military officers) put one in position of power. For most, this is not the goal, but tremendous responsibility instead.

          • DoubtfulGuest

            I get it. If you saw my other response, I don’t think there’s any conspiracy. I was only responding for myself to PH’s question. I have some power in my profession, I suppose, just not at the personal level in the same way. That’s not why I chose it, either. I do know something about trying to make the world a better place. You’re right, it is a responsibility thing.

            On PH’s side a bit, I have been personally harmed by a doctor’s puffed-up sense of his own moral superiority. He treated me as a drain on society’s resources just for seeking care, and ultimately accused me of faking my progressive neurological disease with no evidence of any wrongdoing. The notion that *I* might be *contributing* something to the world, that my whole reason for seeking care was to increase my productivity, never counted for anything.

            I’ve told the story ad nauseam on this blog. I don’t think he’s power hungry, this doctor. I expect he feels quite trampled-upon at work. My whole attempt at joining this conversation was to address the need for self-reflection and self-correction in all people, including doctors.

      • PoliticallyIncorrectMD

        Most of the physicians are NOT “willing to play this exact game”. In fact , they would gladly avoid participating…except no one else is vilonteering and they are reluctantly forced to do it. In turn, they are blamed for both – inadequately treating people with real pain and overprescribing to people who do not need it.

        • Payne Hertz

          Forced? No one can force you to write scripts for pain meds. The medical lobby fought tooth and nail for decades to gain a monopoly over prescription meds, especially pain killers. To do this they had to peddle the fiction that doctors could successfully triage between those with a “legitimate” need for these meds and those who don’t. Control of pain medicine translates into massive profit for doctors, hospitals and drug companies, since pain is the number one reason people see their doctors. It would be hard to get $2000 for an ER visit for a toothache if people could obtain adequate pain meds easily elsewhere.

          Far from resisting this horrible burden we have somehow forced on you, medical societies continue to peddle the fiction they can triage between the worthy and the unworthy, and we just need more “monitoring” (by doctors, of course) to keep people from “abusing” meds. In my opinion, it is unethical for any doctor to pretend he is capable of successfully distinguishing addicts from pain patients, and every ethical doctor should resist playing drug cop. I’m not aware of any medical society or more than a handful of doctors who will admit doctors are incapable of this task, and none that fight against it.

          You say no one is volunteering to take this (golden) cross off your shoulders? I will bet my life’s blood that the 100 million Americans with chronic pain, if given a vote, would happily transfer this burden to themselves. But the moment anyone suggests this they will be attacked by doctors and their lobbies for obvious reasons, just as you did in your other post.

      • SteveCaley

        Not to thump this dead horse too much, but there is no diagnostic instrument, test or imaging that can compete with a GOOD physician with an OPEN mind and enough TIME with the patient. THIS is why our forms-based, check-block, paperwork mill is BAD. It keeps doctors from doing what they do.
        I saw a consult on my fourth year Neurology rotation at Boston City. Patient alleged to have a seizure. 21 year old black female. I stopped a few feet short of the hospital room, as there was a hand firmly grasping my ankle. Attached to a person who fit the description of the patient. She was moaning. She said she needed morphine for her pain. Having nothing more urgent to do, I helped her in the room to do the consultation. She knew she needed morphine. This was the worst belly pain of her life. Not quite knowing what else to do, I examined her belly. All sorts of normal stuff was easily felt; nothing was tender in the least. I talked to her some more; she was writhing about in pain. (People with peritoneal and joint pain lie perfectly still, as movement makes them worse.) I asked her all sorts of things; this pain had been coming on for two or three days; never had anything like this before. She’d been on a diet; sometimes she felt bad when she was trying to lose weight, but nothing like this.
        No nausea/vomiting, no chance of pregnancy. I asked her if she used heroin; she admitted to it now and again, and she sure would like some now. I asked her if she drank alcohol. She tried it once. It made her sick.
        Nothing else on the examination was notable, except for 4+ knee reflexes that were so extreme they looked like complete baloney. I told here that the Neurology team would visit within an hour or two; we did.
        It turns out, morphine was exactly right for what ailed her, and a lot of other things too. I told the Attending Neurologist that she may be having a first onset of Acute Intermittent Porphyria; that she was. He tapped her knees; he made EVERYONE tap her knees – and then he called the Intensive Care Unit.
        People with AIP have a habit of dying all of a sudden, but she didn’t. They lose the ability to breathe; a nasty way to go.
        More often than not, 21-year-old African American females who have a history of heroin abuse, who crawl out into the hall and grab your ankle seeking morphine for abdominal pain that is absolutely undetectable on examination, well, I suppose they might be drug-seeking.
        Being a good doctor means seeing the rose – SEEING the rose. Letting it unfold. 21-year-old females with severe abdominal pain from anorexia, and alcohol; and hyperreflexia; may damn well have AIP.
        Today’s medicine means making the five-minute diagnosis on consultation. She was probably drug seeking, based on his history and examination. But probably means nothing, if you take your patients one at a time. I still think I am a VERY cool cat for making that diagnosis; no wonder the resident gave me a “low pass.”
        And I’m grateful to that patient. She taught me more than any attending ever did.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Maybe a “surprise” house call would clear things up? Been doing a few of these lately. Of course, very inefficient way to make money as a doctor. But quite fulfilling. And extremely revealing.

      Question #2 – your personal responsibility is to do your best. To take care of yourself so you can think clearly and care for others. Docs would all function better with self-care (bathroom breaks, lunch, time off) – get out of survival mode if possible. Compassion fatigue and high-overhead, high-volume clinics makes caring for any patient more challenging. So . . . being alert and well rested and able to connect with your patient will help you read patients more accurately I’d think. Experience is ultimately our greatest teacher. We learn the most from our most challenging patients. Embrace the journey with gusto . . .

      • ninguem

        Some chronic pain practices do that, and it has been advised. Random pill counts.

        From time to time, you run into the type that uses the opiates and benzos on more of a binge basis, and the random calls show the patient is intoxicated, or has five days of pills from a one-month supply, at the end of the first week.

  • Payne Hertz

    Pain has been severely undertreated in America for the last 100 years since passage of the Harrison Act. Millions have lived and died in that time without access to pain relief. The medical profession has only been paying serious attention to pain for the last 20 years, and still pain is severely undertreated in the US. 50 percent of terminal cancer patients report their pain being underrated. This doesn’t look like altruism to me.

    I have been involved in chronic pain support groups for 20 years, and I never met a single person who hasn’t been abused by the medical system. The abuse goes way beyond just denial of pain treatment, which is bad enough. That abuse occurs everywhere, not just in ERs.

    “An absurd amount of people show up everyday in ER’s all across the USA looking for painkillers. If you have never requested a narc report on a state registry for a patient, I can assure you they can be impressive. These are the people that are ensuring you are being treated with a healthy dose of skepticism when you show up at 2 am for horrible chronic back pain and a history of several back surgeries wanting specific narcotics by name.”

    Pain is the number one reason people go to see doctors. Do you think there might be an association between being in severe pain and feeling desperate enough to go to the ER? If people had viable alternatives, I doubt they’d be lining up to spend $2,000 and waiting 10 hours to get 10 Vicodin or be labeled a drug-seeker, depending on the doctor’s mood.

    Prescription drug registries are not proof of drug seeking. They are in fact “proof” of nothing but that a lot of people have to doctor shop to get their pain treated, and are stigmatized as drug addicts when they do. They are a state-sanctioned blacklist where guilt is assumed into existence and punishments meted out based on completely arbitrary criteria with no due process of law whatsoever. Patients cannot even access these databases to challenge or explain any inaccuracies in them. In any civilized country something as fascistic and extralegal as this would be outlawed.

    The idea that knowing what drugs work for your pain is proof you’re an addict is of course absurd.

    The “pain management” courses you are describing regard advanced and complicated chronic pain patients. Managing these people is a different beast altogether (that is why pain management is its own specialty). Every doctor knows proper and safe narcotic prescription practices, because they are the most common medications we prescribe starting day one of residency. To imply that we as a profession do not have adequate education is simply ignorant.

    That’s not true. Read the article again. They make a clear distinction between the training most doctors receive (average 11 hours) and specialized pain management programs (obviously more than 11 hours). When I see doctors claiming that patients in severe pain cannot eat, that pain always elevates your blood pressure or that knowing the name of pain medicines makes you an addict, I am afraid I am not the one suffering from ignorance.

    Fact: We live in a society that abuses the “Emergency” medical system.

    When people have to spend $2,000 and wait 10 hours to get relief for a toothache or get labeled a drug-seeker, I don’t think it’s the ER system that’s being abused. This is another example of how the system is rigged to produced massive profit for something it should cost pennies to treat at home.

    “Fact: If you show up in an ER in this country with no apparent injuries crying out in pain, you will likely be treated with eyebrows raised.”

    That’s true, but thanks for proving my point about the lack of pain education in this country. Any doctor who expects to find an injury at the base of every complaint knows nothing about pain, especially chronic pain.

    “Fact: If you want to have your pain treated adequately you need to establish care with a primary care doctor. These physicians are the ones who will know you as a patient and can properly treat your pain without fear of legal retribution.”

    As many studies have noted, most primary care doctors are not qualified to treat pain. Even when they are, not everyone is willing to treat pain particularly if it requires “high” doses of narcotics (ie more than 30 Vicodin). There is one pain specialist for every 28,000 patients. Do the math and stop blaming patients for this dysfunctional system they have no control over. Your expectations of what people should do are completely unreasonable given the realities of this system.

    “Despite the high prevalence of chronic pain, physicians are often poorly trained in managing the condition and have expressed considerable frustration as part of the emotional toll of that management.2,3 Upshur et al4 surveyed patients from 4 primary care facilities, who reported feeling distrusted and disrespected; physicians were also perceived as dismissive of pain symptoms that patients reported.”

    http://www.jaoa.org/content/113/8/620.full

    “Fact: If you are one of these people who have come to my ER with legitimate pain and were under treated I am truly sorry. I hate that aspect of my job more than any other. I want to make you feel better. I want to take away your suffering. I wish I had a perfect pain meter in my clinical skill set, but I do not. I hate that a few bad apples have ruined everything for those who are in need.”

    Those people you perceive as “bad apples” are not responsible for your behavior, you are. It’s your choice whether to believe your patients or pretend you can distinguish those with real pain from those who are faking it. You can’t.

    • PoliticallyIncorrectMD

      It there a possibility that the cancer, NOT the system is responsible for less than ideal pain control in oncology patients?

      By the way, most of the people coming to ED for pain medications do not pay $2000. This is what they might be charged. In fact, they are likly not paying anything at all, otherwise they would not be able to visit multiple emergency departments on weekly basis with surprising consistency.

      • Payne Hertz

        I’d like to see your evidence for this. Unless you use an assumed identity or are an illegal alien, the hospital can and will come after you for that money. You might be able to be seen for free every time you come to an ER, but no one is going to give a frequent flyer pain meds at every visit so you will just be accruing a massive medical debt for nothing.

        Common sense dictates that bouncing form ER to ER to maybe get 10 Vicodin at a time is an extremely inefficient way for a drug addict to feed his habit. That wouldn’t last the average addict a lazy afternoon. There aren’t enough hours in the day to visit the number of ERs you would have to hit to feed even a minor habit.

        Given this reality and what I have seen from years in chronic pain support groups, the problem is not that you are inundated with drug addicts but that the majority of people you label as such have been falsely accused.

        Re: cancer treatment, no, studies have shown the opposite and uncontrolled pain is the result of inadequate treatment in most cases. I have seen this first hand many times.

        • PoliticallyIncorrectMD

          Sure those ER visits are not free…the rest of us are paying for them from our taxes.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Given the prevalence of compassion fatigue. it is always best to be clear about your chief complaint (REAL reason for coming in) and your objective for the visit. The sooner the patient can clearly state what they want, the faster the doctor can do their job.

    At all costs, avoid the “oh, one more thing. . ” as the doctor is leaving the room. Or revealing your real reason for the visit at the end of the appointment.

    • DoubtfulGuest

      There is the danger of appearing “too smooth” to a substantial minority of doctors, though. Clear, concise, polite, considerate, don’t go over well with everyone.

      • http://www.idealmedicalcare.org PamelaWibleMD

        As my musician ex-husband always used to say: Play to the room.

        • DoubtfulGuest

          I don’t quite understand?

        • DoubtfulGuest

          Dr. Wible, I’d like to clarify that in one situation I’m referring to, the physician was…impaired. Suffice it to say he had a medical situation that prevented him from correctly interpreting normal, polite behavior.

          I feel that your statement places blame on patients. Like if something goes wrong, it’s because we didn’t calibrate our performance right.

          As applies to pain treatment, many doctors feel suspicious of patients who have a very clear objective. I feel that Martha55 did fine with her doctor. Many docs want to choose medications themselves, and they don’t like to hear suggestions. It looks like Martha55 might have been punished for trying to be respectful. And for not being a mind-reader.

  • http://www.doccallum.com Martina P Callum MD

    Pain should always be treated. Who am I to say you don’t have pain. An accident victim with a history previous back surgery on a back board for 5 hours! And sent home in pain without adequate initial pain control..THAT”S JUST CRUEL!! Working in the ED I often patients see with an alleged history of chronic pain coming to the ED in off hours and weekends when they can’t get in contact with their doctors asking for pain medication. I don’t think it’s unreasonable to give people a 2 to 3 day supply until they can reach their PCP. But I also think it’s important to let that patient know you won’t be treating his chronic pain condition in the ER. Some state pharmacy boards have a website you can log onto to look up a patient. This helps to weed out the drug seekers. I am assuming the 1st patient in the post was in a clinic/office type setting..good idea to check the drug screen but I wonder if other types of abuse were also going on. I also think that we (physicians) are part of the problem. Far too many times I have seen my colleagues repeatedly give out scripts with large quantities of narcotic analgesics from the ER. I worked in one ED where the medical director wrote guidelines for the doctors to follow…this helped because sometimes I think some of us suspect drug abuse but are too scared or do not know how to say no.

    • http://www.idealmedicalcare.org PamelaWibleMD

      We’ve really managed to perpetuate a fear-based profession. We need to renew the sacred patient-physician covenant. Get back to healing. . .

  • PoliticallyIncorrectMD

    Evidence for what, that cancer can cause intractable pain?

  • PoliticallyIncorrectMD

    How is this relevant to our discussion? Also 10% of health care expenditure is not the same as 10% percent of Physicians. NIce try though : )

  • gwen rothberg

    the problem with opiates is that they really just don’t work that well. They block one or two receptors, and then one of the other 28 sensory receptors take over and render the med useless, unless we titrate up…and up…and up. I know its not very popular with the big drug manufacturers, but I have seen patients have considerably better success at pain control with topical compounds. Very off label, requires copious patient teaching and excellent pain assessment, but if you can find a good compounder with a quality lipophilic base who is willing to partner with you, we can fill those receptors topically with gabapentin, diphenhydramine, ketamine, benzos, baclofen – until we get good control. Apply to the dermatome and at the terminal site, repeat q 4-6 hours. No chance for abuse, and suddenly the patient can participate in therapy, and continue their ADLs. As more and more prescription drug coverage can be applied to this, it may solve our drug problem, which happened on our watch over the last 20 years. Better patient teaching will be a major endeavor even for those that remain on PO opiates, but the outcome will be worth it.

    • sparklingsoul

      I use gabapentin/ketamine/ketaprofin compound cream on the entrapped nerve in my foot where I had surgery. It works great for mild to moderate pain; it does not work for severe pain. Also, how do you put topical pain meds on your intestines or on your bladder? Not all pain is external.

      I also sell a topical NSAID; it works great, but insurance doesn’t cover it. It’s very expensive. Insurance also doesn’t cover the compounding cream that I use for many patients; those patients would need to fork over $500 to cover this cream.

  • Maura69

    Several years ago I went to the ER for a severe Migraine. The nurse came in and took my vitals and then the Dr came in with several papers in his hand and asked me if I took all that medication…narcotics…I was stunned and asked him what he brought in, (I couldn’t visualize because of the migraine) he asked again if I was the one who took all the medications. I replied yes and he left. I then told the nurse how appalled I was that before even talking to me he brought those DEA sheets. She then went out and reported to the doctor, he in the meantime took the time to check out my medical file, (quite extensive and for over 40 years), came back in and apologized. After realizing what my problems had been and still are we became very close friends. No he doesn’t treat me and I have only received pain medications from one doctor. Even when I have had to have back surgery, neck surgery, knee and hip transplants and many more surgeries I only have one (1) physician prescribe my meds. Addiction is a very serious problem and I personally am very well aware of this. I do fear having to go to another area or hospital that might not have my history.

    • RuralEMdoc

      That was a little tactless of him. I never bring up the drug registry (we call it a MAPS in my state) to the patient until I absolutely have to.

      The story does illustrate exactly how we use the registries though. Patients think that because they have pages and pages of narcotic prescriptions, we will think they are addicts, but that simply isn’t true. The registry is used to ensure that the story you are telling us checks out.

      If you have a headache and the registry tells me that you have had three prescriptions for 10 Vicodin each filled in the last week, then we need to have a conversation.

      It is important that you realize that most ER docs hate the suspicion that we are forced to harbor. Migraines are horrible, and your pain should be treated as adequately as possible.

      The reality is that every one of us has been tricked by drug seeking addicts more times than we’d like to admit. It is eye-opening when you get burned.

  • DiNovia

    “Anyone have a quick and easy solution?”

    You’re kidding, right? This conundrum was not created quickly nor easily, so don’t count on a quick or easy solution.

    First, ask why the situation exists. Income equality, economic collapse, joblessness, homelessness, and the gutting of US mental health care facilities all play a part. As does prejudice, racial stereotyping, and a disturbing dismissal of women’s health care concerns as “all in their head.”

    Anecdotal case in point: I am a white, female with a chronic gastrointestinal condition that includes pain. I was working at a hospital clinic when I apparently came down with a mild case of pancreatitis. My coworkers recognized the problem early and sent me to the ER. Two beds away from me was a young African American woman who was in the ER due to sickle cell crisis. She was in excruciating pain, writhing on the gurney, She had already been in the ER for over an hour with no pain intervention.

    I arrived and two doctors from my clinic rounded on me within 5 minutes. Another 5 minutes and I had 6mg of morphine on board to help with my 5/10 pain. The young woman two beds down began to cry, then to scream. The pain was clearly debilitating. Instead of sending a doctor, the hospital sent a patient advocate that told her that if she couldn’t quiet down, they would call the police. The young woman locked herself in the bathroom with her cell phone, crying to her boyfriend. The young woman’s mother, a quiet and patient woman, came to me. TO ME. To apologize for her daughter’s behavior. She said, “I hope she isn’t disturbing you too much, miss.”

    I took this woman’s hands in my own and I told her that what was happening to her daughter was completely inappropriate. That it was I, not her, that should be apologizing, That I was appalled by her daughter’s treatment and the clear difference in treatment that I received. How many times had this young woman come to the ER in sickle cell crisis and received similar treatment? How many times had doctors weighed her diagnosis and historical treatments against her skin color and her socio-economic status and had treated her like a criminal just for seeking treatment? She had an IV line in and was receiving fluids. The nurses told her that her transfusion order had been placed and would be there shortly. Yet no one would give the order for pain intervention, no matter how much this woman cried, or begged, and then finally locked herself away. The entire event has disturbed me deeply to this day.

    Yet, when I have been underemployed and without medical insurance, I, too, have been deemed a “drug seeker” and a malingerer, even though I have lost organs to my chronic gastrointestinal condition and am under the care of specialists.

    Quick and easy solution? Don’t bother. You can’t put a band-aid on an arterial wound and expect improvement.

  • RenegadeRN

    Sadly I found out the insurance companies would MUCH rather pay for hydrocodone than Celebrex!
    For a year prior to bilateral knee arthroplasties I was in major pain, Celebrex worked well and I preferred it…I had an INSANE time getting it approved, even when I needed it for a couple months after both surgeries.

    The shenanigans used by my insurance were ridiculous and seriously just pissed me off! Obviously a recent history of surgery was not reason enough…arghh!

    • Martha55

      I didn’t even get to the point where my doctor and I talked about alternatives for pain management.

      At the time I had a Cadillac health plan provided by an employer that cared about his employees. There probably wouldn’t have been an insurance barrier.

      • DoubtfulGuest

        I feel that your doctor should have handled this better. If you made an open-ended request, that implies some deference to her judgment. Many docs just want to hear the symptoms and then they decide what, if anything, to do for you. I’m not sure you did anything wrong, and it sounds like a good 2-3 steps away from any point your doc should even have wondered about that.

  • sparklingsoul

    When I was young (early twenties) I had a bad neck sprain. Fearing opiates, I opted to take NSAIDs and tough it out. Big mistake! The pain was severe and lasted three months (the only reason it ended was that I miraculously found an acupuncturist who was able to relieve the pain in a few weeks).

    The result of not treating my pain adequately was: Loss of income from being unable to work for three months; huge medical and acupuncture bills; duration of pain that may have ended much earlier had I treated it adequately; extreme mental distress and depression; loss of sleep; terror that in the future any pain could turn into another long-term nightmare.

    Had I simply taken the Vicodin my doctor had prescribed, I may have been able to prevent the pain from escalating and taking over my life.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Good summary sparklingsoul. Question: How did you get into your profession of (legally) selling opioids to doctors. Did you need any special training beyond high school? College?

    • sparklingsoul

      Thanks, Pamela.
      You’ve asked a great question about my training. I think you will be surprised at the answer:

      I’m a licensed psychotherapist (master’s level) who specialized in treating patients with chronic pain.

      I have ten+ years of pharmaceutical sales experience, including institutional sales. Most of my colleagues have at least a decade of pharmaceutical sales experience, because this field requires advanced knowledge of pain and its treatment, pharmaceuticals, the regulatory environment, medical institutions, the insurance industry, and pharmacy practice.

      Big Pharma typically provides a month or two of formal disease-state training to sales reps each year. I’ve attended about a dozen specialist-level professional conferences. I’ve attended hundreds of hours of grand rounds, fellow case conferences, and resident conferences. I’ve watched doctors perform medical procedures at teaching hospitals, and I did a preceptorship with an internist.

      At this point I have gained enough general medical knowledge that I can attend a medical conference for primary-care physicians on almost any topic and understand what is being discussed.

      Interestingly, most of my colleagues have experienced serious acute pain or chronic pain, or had major surgeries, so we also have a lot of empathy for these patients.

      Because my colleagues and I are middle aged, we aren’t as noticeable as our bouncy, young blond counterparts who never make it out of entry-level sales:-)

      • http://www.idealmedicalcare.org PamelaWibleMD

        Thanks. Bouncy blonds remain at entry-level positions?

        • sparklingsoul

          The “bouncy blondes” are the young, chirpy reps who give pharmaceutical salespeople the reputation of being not too bright or educated.

          They rarely move up the ladder to specialty or institutional sales because they are bright enough to deliver a scripted sales message but not bright enough to truly understand the mechanism of action of the drug or physiology.
          For example, an entry-level rep can tell you how her ACE-I works but probably can’t tell you how the RAAS operates; an advanced sales rep would know this.

          Pharmaceutical sales companies hire these cute blondes for “mass market” sales positions (i.e. selling blockbuster ARBs and statins) because the companies simply want to them to deliver a scripted message en masse and be cheerful and likeable.

          Specialty and hospital sales reps act more like consultants and may have advanced degrees or come from a medical background, such as nursing. They would be expected to have a thorough understanding of hypertension and concomitant diseases states, such as diabetes and heart failure.

          I hope this clarifies:-)

          • http://www.idealmedicalcare.org PamelaWibleMD

            Have the low-level blonds heard this from a higher-level man? I’d like to be a fly on the wall for that conversation.

          • sparklingsoul

            My point is simply that doctors can feel confident that the reps who sell them CIIs are very bright, well educated, ethical, and able to think critically.

            On the topic of “blondes,” the majority of pharmaceutical managers (in Big Pharma) are men, which may explain part of the chirpy blonde phenomena. At the district manager level, about 75% are male; at the regional manager level, around 85% are male. If you look at the photos of the C-level executives of pharma companies, usually only the head of HR is a woman.

            In entry- and mid-level sales positions, there are many Black, Asian, Middle Eastern, and female reps, but as you rise up the ranks, you see mostly white, male faces.

            I don’t know whether this mirrors other industries, but I really hope it changes.

        • ninguem

          I prefer eye level.

  • http://www.idealmedicalcare.org PamelaWibleMD

    100% agree with Payne Hertz.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Solution: DISINTERMEDIATION. Docs need to be on the forefront of removing no-value-added intermediaries if we are to have any hope of salvaging our profession.

  • http://www.idealmedicalcare.org PamelaWibleMD

    My patients are overjoyed when I pop in. Never had anyone dissatisfied. Quite the opposite. I think they call all their friends and relatives and brag on it when I leave. Have you seen my house call photoessay? This guy was over-the-top ecstatic:

    http://www.idealmedicalcare.org/blog/why-i-love-house-calls/

  • sundance1984

    No, that it NOT the definition of “chronic pain syndrome.” That is the definition of chronic pain. “Chronic pain syndrome” describes a maladaptive response to the REALITY of chronic pain, most often manifest in co-occurring depression and/or chemical dependency. After more than 20 years in Onc-Heme, then hospice&palliative care, I am still appalled at the remarkable ignorance among the healthcare professionals, esp. MDs, who purport to understand pain management then demonize the patients who most need their (sadly lacking) skills and compassion.

    Addictions of all kinds are wicked, chronic, and if not managed, FATAL diseases. There are well defined and validated approaches to managing chronic pain, including non-malignant pain, in our literature. Please, please learn how to care for pain patients — OR stop pretending!!

    • PoliticallyIncorrectMD

      Is solution to “maladaptive response to the reality…co-coouring depression and/or chemical dependency” is giving more pain medications? Honest question, I am not being facetious.

      • http://www.idealmedicalcare.org PamelaWibleMD

        How about a referral to a medical intuitive?

      • sundance1984

        We know that holistic, team-based and patient centered care has the best chance to provide opportunities for healing. The collaborative “patient centered medical home” model is especially apt in addressing the “total pain” suffered by patients with chronic pain, psychiatric co-morbidities, and the spiritual and and social deficits commonly involved. Chronic pain syndrome is a complicated and holistically SELF-destructive disease. So the solution must be holistically restorative.

        • PoliticallyIncorrectMD

          Completely agree. But wouldn’t you think that more restrictive / cautious opioids use BEFORE one develops chronic pain syndrome may save us lots of efforts later, AFTER one develops psychological and physical dependence ?

          • sundance1984

            I believe that all providers who prescribe opioids should establish and maintain the knowledge and assessment skills to do so attentively AND to the established standards of care which DO exist! The research clearly demonstrates a vicious cycle between chronic pain and depression at the neurotransmitter levels. It’s also clear that chronic pain changes the way body works — it truly is a distinct, progressive disease state that CAN be managed, and really must be managed, ideally collaboratively applying the expertise of a multidisciplinary team. That IS the international standard of practice.
            Physical dependence is inevitable, as it is with other classes of drugs. Addiction is a PRIMARY, complex neurobiological, spiritual,
            and psychosocial disease. There is an ironic condition known as “pseudo-addiction” that is typically iatrogenic — undertreatment of pain is dangerous as well as inhumane. I’ve written CME items on pain management for family medicine, general and geriatric.
            Thank you for your dialogue!

  • sundance1984

    Thank you! At the well-regarded U of Utah Pain Management Center two basic requirements are a referral from a primary care physician, along with a commitment by that pc physician to manage the patient’s pain AND all their health needs following the Center’s multi-disciplinary recommendations.
    This is not rocket science. But it demands our empathetic attention!

  • sundance1984

    Percocet contains oxycodone in varying amounts ranging from the very lowest at 2.5 mg to the higher end of 10 mg along with acetaminophen (Tylenol). So you must see that you were indeed prescribed oxycodone! The vast majority of us are extremely unlikely to develop true addiction which has a well-established genetic pre-disposition. Virtually everyone can and will become PHYSICALLY dependent upon the effects of OPIOID medications. Not OPIATES, unless the medication is morphine — chemically similar to heroin. That simply means we experience withdrawal-like symptoms if we stop taking the medication abruptly. Duh!

    I’ve lectured at Yale and a number of other universities in the Northeast and So California on pain and symptom management. We have two persistent enemies of compassionate, effective, and safe management of chronic pain = ignorance and fear. When we use perjorative and truly inaccurate terms such as “narcotics” and “addiction” to describe opioid medications and the physical dependency that affects EVERYONE who uses these medications over time we diminish our humanity and professional expertise — if we HAVE it!

    NO provider should prescribe any medication for any patient without accepting total responsibility for their management of their patient’s symptoms/condition. Is that so radical? Pain is a real, demonstrable symptom.
    If you do not know how to quantify your patients’ pain then for God’s LEARN! The fundamental clinical problem of pain, and then chronic pain, is that pain changes the body’s immune functioning; chronic pain becomes an ICD-10 defined condition with real potential sequelae including a wicked dysphoric synergy between chronic pain and depression — at the neurotransmitter level!

    Remember our oath and commitments!

  • Lisa

    Scar tissue and nerve damage causes pain so it is possible to have pain after an injury heals. I don’t care what you call it, it is still pain.

  • buzzkillerjsmith

    Oregon. Say no more.

    Of course some of my best friends are Oregonians. Not really.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Wha?

  • PoliticallyIncorrectMD

    “I sell opioid pain medications to hundreds of pain specialists”… You should use this disclaimer on all of your comments about the issue. Sounds like a conflict of interest to me : )

  • PoliticallyIncorrectMD

    From this blog today:

    http://www.kevinmd.com/blog/2014/04/physicians-curb-overthecounter-medicine-misuse.html

    “it is estimated that more than 126,000 hospitalizations and nearly
    17,000 deaths in this country are linked to overuse of over-the-counter (OTC) pain medicine ingredientsit is estimated that more than 126,000 hospitalizations and nearly 17,000 deaths in this country are linked to overuse of over-the-counter (OTC) pain medicine ingredients”

    You want to increase this number by making opioids OTC?

    • http://www.idealmedicalcare.org PamelaWibleMD

      Good point.

  • PoliticallyIncorrectMD

    While many on this forum point out that the physical addiction to prescription opioids is real and it has to be treated appropriately, they seem to ignore the fact that the indiscriminate use of this agents may be responsible for the development of this problem to start with.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Yes, there are far more useful agents that are never given a chance.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Health care requires caring. Caring takes time and a reservoir of compassion. Both may be absent.

  • http://www.idealmedicalcare.org PamelaWibleMD

    I guess it’s like dating. Have enough bad relationships, one may consider never dating again or being cynical about men or women. . . Maybe it’s human nature. . . .

    How would one update their evaluate skills?
    I’d love to watch this. I err on the side of being to trusting so I’d probably fail to correctly identify the manipulative patients.

    • DoubtfulGuest

      Dating is not like being at work. I, too, feel that this post crossed the line to blaming innocent patients. Updating evaluation skills — well, there’s the “objective signs” part which may or may not apply to a pain evaluation? Then there’s the doc’s ability to “read” a person, which…is often not that great, and people get hurt all the time on both sides.

      In personal situations like dating, society is sympathetic – to an extent – with jaded people, but also tends to encourage people to trust again, to let go of things, to try to see each new person with fresh eyes. People are not allowed to “hold on to” those feelings forever and let bad experiences inform everything they do. Dating, friendships, coworkers, whatever. The doctor-patient relationship isn’t really like any of those others, but I’m trying to address the emotional hurt, the “human nature” part of what you’re saying.

      Please look closely at some of the language in this post. I don’t even need pain treatment, and I don’t think it’s okay. There’s a troubling lack of differentiation between patients who are honest and those who are dishonest, facts and evidence aside.

  • guest

    It’s a tricky question…perhaps you do have a “right” to convince me to prescribe more pain meds than is safe for you, by deliberately not taking them the day you come into my office, so that you appear more alert than you normally are if you take the meds as prescribed.

    Does the “right” to make your own choices about how dangerously you want to take pain meds, supercede my right to prescribe safely so that I don’t contribute to your death by overdose? Does the “right” to privacy and boundaries only apply to whether I am allowed to do something that provides more objective information about how you are functioning on the medications I am prescribing? There is also a “right” that your doctor has to be able to expect that his or her patients are being truthful with him. What does one do when one “right” is in conflict with another?

    • http://www.idealmedicalcare.org PamelaWibleMD

      Flip a coin. Pray. Divine guidance.

      Murky water indeed.

  • https://www.facebook.com/itsnotallinyourmind?ref=hl Liz

    As a chronic pain patient, I have been begging for something other than
    drugs and it has been so difficult. I have neuro-muscular issue with the
    left side of my body. After 8 years of going doctor to doctor, I had
    botox in my neck and it help soooo much. I was getting the nerve pain
    addressed in my leg with injections then my husband took a job in a new area. I had to start all over again with new doctors. I was lucky to work for the hospital where I used to live so most of the doctors i saw took me seriously and did not see me as a drug seeker. Since we moved I have been trying to get botox since last August and am fighting an uphill battle with a neurologist who has seen me once (my in network neurologist does not do botox so he had to refer me to another neuro). She doesn’t seem to think I need it. I keep calling her office to discuss the matter and I get no response. I guess neck pain, blurry vision, vertigo, stabbing pains in my head and throwing up aren’t good enough reasons for her. I don’t want to take medication but it is all I have. I know there are treatments ( besides drugs)out there that can help people but what is it so hard to get a doctor to go that route?

    • http://www.idealmedicalcare.org PamelaWibleMD

      Some treatments require out-of-the-box thinking. Many volume-driven big box clinics thrive on cookbook medicine and cookie cutter doctors. Want Rosemary in your mashed potatoes? May not be on the menu.

  • http://www.idealmedicalcare.org PamelaWibleMD

    159 comments and the quick-and-easy solution is ___________________.

  • http://www.idealmedicalcare.org PamelaWibleMD

    Some may be baffled by your condition. They may not know what to offer you. They may feel a sense of failure. Other may just have compassion fatigue.
    What do you think Liz?

    • https://www.facebook.com/itsnotallinyourmind?ref=hl Liz

      Baffled indeed. I have come to the conclusion that I may never find an answer but then again it took my sister 20 years to get diagnosed with Parry Rhomberg syndrome! The thing I appreciate most is when a doctor emphatically admits yes there is something going on and but they just do not know the answer. I am ok with that after 10 years of dealing with this. The wall I seem to hit is getting the symptoms treated to improve my quality of life. I worked as an exercise specialist with the last hospital I worked for and taught exercise classes to cancer patients, post-rehab and special populations. Fortunately I was able to move into a less physical role as a health coach but I have given up many of the things I love because I know they will exacerbate my symptoms. I am on a quest to figure out how to help myself and people like me to best navigation the system, better communicate their needs to their healthcare provider and also practice self-care. I would like to be part of the solution by turning this experience into something useful and positive. And yes, I have no doubt compassion fatigue can be a factor. One of the other things I have learned in all this is how many patients doctors see in a day and the frustration of not being able to spend more time with patients. Any advice on how to best approach doctor appointments is greatly appreciated. I have an appointment with a new pain management doc next month.

  • SteveCaley

    I have treated patients with chronic pain, and you’re right – you don’t fight the last war, or treat the previous patient, but the one in front of you. The problem with mentioning a “need to update their evaluation skills” is that the evaluation of chronic pain depends primarily on how the patient describes their condition. Some ‘patients’ are complete phonies and are obvious from the get-go; others are not.
    It’s not always just the physician’s bad call – I’ve had some patients come in and “bulldog” – intimidate and pressure very subtly – to get what they want. Treating chronic pain is VERY hard, and again, there’s no substitute for ongoing care and establishing a rapport with a patient.

  • SteveCaley

    Wow, nailed the Major Issues there well. I got suspicious when I told a patient that I couldn’t call in Vicodin because it’s a CII drug. She said, no, it’s a CIII drug; Percocet is a CII drug that can’t be called in. There’s a tip for ya.

    Chronic Pain Management is one of the areas of medicine most fragile to fragmentation and dysfunction in the system. It’s where the break shows up most “symptomatically.” The problem is in fragmentation and dehumanization, not just pain management, IMHO.

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