Over the past few months, more attention has been paid to the prescription drug epidemic, with increasing rates of accidental deaths noted across the country. Legislatures in different states are currently considering laws to provide first responders access to reversal agents, such as naloxone, to treat people found on the scene who have likely overdosed on these medications. With increasing media coverage, the public is becoming more aware about the abuse potential of certain drugs and about things to watch out for in terms of signs of drug overdose. However, not as much attention has been focused on the challenges posed to the people legally allowed to prescribe these medications in the first place: the health care providers.
Certain health care providers (consisting of doctors, nurse practitioners, and physician assistants) have the ability to provide prescriptions of drugs to all patients that they come across, including certain drugs noted for their abuse potential, such as oxycodone, hydrocodone and morphine. These drugs are considered Schedule II drugs under the United States Controlled Substances Act, meaning that they have a high potential for abuse, and that they have accepted medical use with severe restrictions for treatment of certain conditions due to their abuse potential. Chronic pain is a common medical condition for numerous patients, whether from recent trauma leaving residual pain, or from progression of conditions that lead to nerve damage, such as diabetes. Many patients with chronic pain do not have a history of substance abuse, so prescribing these medications is less of an issue. It is when a patient with chronic pain and a history of substance abuse presents to the hospital that adequate treatment of pain becomes more challenging.
I saw this challenge first hand in experiences during my internal medicine residency training and my first year practicing independently as an attending physician. I trained and ultimately practiced in a state that has one of the highest rates of prescription drug overdose and accidental deaths in the country, so this challenge came up numerous times. Frequently, a patient would talk about a particular traumatic event that led to them having chronic pain, but a urine toxicology screen would also test positive for an illicit substance which indicated recent substance abuse. Instantly, the validity of the patient’s story would be called into question with the positive drug test, and the concern about potential prescription drug abuse began to surface. In that moment, physical exam findings and review of images became important in determining if there was any objective evidence substantiating the patient’s complaints. If not, the decision about whether or not to provide a prescription of pain medications became more difficult.
This is a common scenario faced by health care providers on a daily basis, whether in the inpatient or outpatient setting. We are expected by the general public to provide adequate health care to patients, addressing both acute and chronic problems. However, chronic pain is a challenging diagnosis to treat effectively due to the subjective nature of the complaint. The only person who knows how much pain one is in is the patient, and there are few tools available to adequately assess the complaints objectively besides physical exam findings and review of the medical record to substantiate those claims. If there is nothing that can be found, a decision has to be made in terms of whether or not to believe the pain complaints of the patient at that moment, and it never is an easy decision.
Far too often, there are previous situations that complicate the decision we have to make about providing pain medications. Sometimes, we have had patients with a clean drug test who present with chronic pain; unfortunately, they are later found to be abusing the medications we provided to treat their pain. Other times, we take care of patients with a recent substance abuse history that we are reluctant to give pain medications, but they turn out to have an actual medical issue leading to their current pain. It frequently feels like a guessing game, only the stakes are higher given the potency of these medications.
Schedule II drugs are a double-edged sword; they can be very effective in providing comfort for the patient who struggles with pain, but they can also be addictive and potentially life-threatening. The medicolegal ramifications are all too familiar to us since we know that we can be held liable for not adequately treating pain in the eyes of a patient. Also, if an adverse event that happens to a patient is attributed to a prescription of what is thought to be an excess amount of pain medications, we could be held responsible for that event. The potential threats to our livelihood in these situations ultimately leaves us in a tough predicament when the issue of prescribing pain medications arises, and at the end of the day, we can only hope to make the right decision when it comes to treating our chronic pain patients. Hopefully we are not burdened with fear when these decisions have to be made.
A quote that comes to mind is one that I hear periodically at church, that we are supposed to be “wise as serpents and gentle as doves.” I believe this can be applied to all health care providers when it comes to how we navigate the prescription drug epidemic. We have to be wise about the reality of prescription drug abuse in our society, but at the end of the day, we need to provide effective and compassionate medical care to our patients when it comes to chronic pain. Perhaps focusing mostly on the medical presentation, and not focusing as much on the social situations in which patients find themselves, may help us to better navigate these challenging waters.
Chiduzie Madubata is an internal medicine physician.