Lying to receive pain medications hurts patients in true pain

My patients lie to me every day. Some tell me that they have been taking their medications regularly when they haven’t. Some say that they have been eating a healthy diet and exercising for at least 30 minutes every day and don’t know where the extra pounds are coming from. Some lie that they are using condoms every time they have sex, that they have quit smoking, and if they drink alcohol at all, it’s only a single glass of wine with dinner. They bend the truth for many reasons: Because they want to please their doctor, because they don’t like to admit lapses of willpower, or because they are embarrassed to tell me that they can’t afford to pay for their medications. I forgive them; it’s part of my job to understand that patients (and health professionals) are only human. The only lies that I find hard to forgive are the lies about pain.

Like many doctors, I have complicated feelings about prescribing for chronic pain. On one hand, I recognize that relieving headaches, backaches, arthritis and nerve pain has been a core responsibility of the medical profession for ages. On the other hand, deaths and emergency room visits from overdoses of prescription painkillers have skyrocketed over the past 25 years, and I have inherited many patients with narcotic addictions that resulted from a prior physician’s well-intentioned generosity with his prescription pad.

Even worse, I’ve had patients I trusted turn out to be junkies in need of a fix. An earnest, well-dressed young man once came to my office complaining of a common chronic condition that, he said, had not been relieved by high doses of over-the-counter painkillers. He convinced me to to prescribe him narcotic pills, and didn’t bat an eye when I asked him to sign a pain contract that required him to return every month for refills and only receive prescriptions from me in person. For the better part of a year, he never missed an appointment, and seemed genuinely receptive to unrelated preventive care that I recommended based on his age and risk factors. His deceit was exposed only after he stumbled, intoxicated, into an acute care facility staffed by a doctor who knew me and requested an early refill of a prescription for a different brand of painkillers prescribed by a third doctor for another imaginary condition. My colleague told him the gig was up, and I’ve never seen him again.

I believe that drug addiction is a disease. So why do I find this patient’s lies (and those from others like him) so hard to forgive? Because they have consequences for people who are truly in pain. For patients’ convenience, I transmit virtually all prescriptions electronically to the pharmacy, but I’m not allowed to do this with “controlled substances” such as painkillers. Wary of encouraging drug abuse, some insurers impose arbitrary limits on the number of pills a patient may be prescribed in one month, which I can only override by spending hours on the phone or not at all. One chain pharmacy recently started demanding signed copies of chart notes that included the pain-causing diagnosis before they would dispense painkillers (a practice that I believe to be an illegal invasion of privacy, but they didn’t budge an inch when I told them so). And worst of all, doctors like me who have been burned before are that much more likely to view our patients with suspicion.

In the July issue of Health Affairs, Janice Schuster described a health odyssey that began with a seemingly minor surgical procedure and ended with her becoming “one of the estimated 100 million American adults who live with chronic pain” — in this case neuropathic pain, or pain from nerve damage that in my experience can be the most difficult type to treat. She wrote about how health system restrictions designed to discourage abuse created obstacles to her obtaining adequate pain relief, and about a lack of compassion from her primary care physician (who “dismissed my symptoms”) and her surgeon (who “said again and again that he had not heard of a patient experiencing such pain”). As the author of a popular self-help book for persons facing serious illness, Schuster understood better than most the public health crisis posed by prescription painkillers, but that understanding offered little consolation as she navigated “the maze of pain management” that has evolved to deal with it:

Pain patients like me often feel trapped between the clinical need to treat and manage pain and the social imperative to restrict access to such drugs and promote public safety … When I am not overwhelmed by pain, or depressed by it, I am furious at the attitudes I encounter, especially among physicians and pharmacists. It has been stigmatizing and humiliating. … Surely, we can find better ways to ease the suffering and devise treatments and strategies that do more good than harm and that do not shame and stigmatize those who suffer.

A few of my colleagues have become so disillusioned with the dilemmas of pain management that they have sworn off prescribing narcotic painkillers entirely. As often as I’ve been tempted to take that path, I won’t abandon patients in pain, for whom the services of caring and competent family physicians are needed now more than ever.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor

Comments are moderated before they are published. Please read the comment policy.

  • doc99

    Patients with chronic pain are collateral damage in the War on Drugs.

    • Kristy Sokoloski

      Exactly. There’s an article that came out in the National Pain Report telling the story of a lady who is dealing with chronic pain and she was saying about how the drug testing and the pain contracts were violations of patient rights. When the link to the article got posted to their Facebook page I asked what then are doctors supposed to do? It’s a fine line between protecting the doctors and the patients, but yet at the same time making sure that the patients who are living with chronic pain get treated adequately. That wasn’t the only news item this week. It is finalized now that hydrocodone is going to be a Schedule II classification. This has been debated on for 15 years along with the idea of whether or not to take it off the market the way they did Darvon and Darvocet. So, effective Oct 5th hydrocodone will be a Schedule II. My Pain Management doctor and I know what to expect as far as how to handle it when that becomes effective. Yes, this recommendation was signed in to law on Aug 21st.

  • http://reviewconcierge.com David Engel

    This is a really controversial issue. I work with a lot of pain medicine physicians at Review Concierge who are bombarded with drug seeking patients who threaten to leave negative reviews if they don’t get what they want. I recently helped a large orthopaedic surgery practice establish a protocol for pre-screening patients. One question to ask is, “How did you find out about us?” If the patient wasn’t referred by another physician, ask some follow-on questions to determine if that patient is open to medically correcting their pain problems… or whether they just need medication.

    One thing that can backfire, however, is the legitimate patients can feel “feel trapped between the clinical need to treat and manage pain and the social imperative to restrict access to such drugs.” It is important to coach your staff to not assume everybody seeking medication is a ‘drug seeker’ and to respond non-judgementally and compassionately in every case when patients broach the topic of pain medication.

    • NewMexicoRam

      Lord, we need Dr. McCoy’s tricorder more than ever. No faking with that gadget!

      • http://reviewconcierge.com David Engel

        When all else fails just switch your phaser from STUN to KILL.

  • SteveCaley

    And society likes to put the lash down on the “Greedy And Wicked Doctors” who prescribe pain medications to those who are not in pain – the drug peddlers. Nobody talks about being bulldogged by these “patients,” who can become scary and threatening indeed.

  • Carol Levy

    Dr. Lin must have an interesting practice. Studies repeatedly show that most pain patients do not become addicted to their narcotic medications. Some may become dependent but that is a very different animal.
    Dr. Lin writes ” I have inherited many patients with narcotic addictions that resulted from a prior physician’s well-intentioned generosity with his prescription pad.

    “Many”? And why is it the patients who lie? The fact that he goes into this with the my patients lie to me attitude I am sure is transmitted to his patients who may well be feeling judged resulting in their feeling they need to lie to him, about compliance, habits etc.

    Doctors on the other hand are “well-intentioned” That seems to indicate bias to me against patients and towards practicioners.

    Moist of us in chronic pain do not enjoy being on narcotic medications. It makes us feel groggy, dry mouther, etc but if it helps to allow us to function, for some, meaning just being able to get out of bed then it is worth the trade-off.

    Pharmacies and the DEA have made it harder for those in chronic pain to get their medications. Docotrs like Dr. Lin who continue the false myth of pain patients and addiction can only make it even harder for those who live with often debilitating and disabling chronic pain.

    Carol Jay Levy, B.A., CH.t
    author A PAINED LIFE, a chronic pain journey
    accredited to the U.N. Convention on the Rights of Persons with Disabilities member U.N. NGO group, Persons With Disabilities

    • T H

      Ms. Levy,

      The fact of the matter is that 1/3rd of all vicodin and norco in CA is diverted to a secondary (translated: ‘black’) market or taken inappropriately.

      Every ED shift I’ve had in the last 8 years, I have had at least 1 if not 4-6 patients claiming ‘they lost their prescription’, ‘my roommate stole it,’ ‘someone stole my backpack,’ ‘they just disappeared.’

      Once? Sure. Everyone has bad things happen to them, but when these people show up 3, 5, 9 times a month with the same story, guess what? I don’t believe them. Did they report the theft? No. What attempts have they made to secure their gear? None.

      You’ll understand, I’m sure, why I am leery of people showing up asking for pain medications.

      TH

  • Mamabear83

    As a patient having undergone several surgeries and chronic migraines, I do agree with this article. I hate asking for and taking pain medication. I am usually given hydrocodone and I ask for the smallest possible dose because I just hate the way it makes me feel. I have never finished a bottle or asked for a refill. In light of that, I am curious to ask Drs how they feel about medical marijuana for pain management. I read on online article a few weeks back, I believe it was on CNN, that read along the lines of, states with legalized MMJ have seen a drop in the amount of deaths caused by prescription drug OD. May I ask, just for tbe sake of discussion, if Drs believe it is at least worth looking into changing MMJ from a Schedule 1 drug so that more research can be carried out? Thanks!

  • Sara Stein MD

    Every new patient (and some old patients) is screened with an OARRS (Ohio Automated Rx Reporting System) Report that the state of Ohio uses – it’s a record of every scheduled prescription they have filled, who wrote the prescription, where it was filled, for how many pills to last how many days, how many refills. Multiple states have the same system, and now the states are beginning to share information. On some patients, we run it every appointment.

    I show them a copy of their OARRS if it’s not clean, and walk them through it, showing them that I cannot prescribe their substance to them because they are abusing. Basically they are busted. I tell them I have the right to notify their doctors and pharmacies listed on the OARRS, or have the state do it. I let them decide the next step – whether we work on this with substitute medications, they go to rehab or treatment, or walk out the door.

    Sometimes the report is clean, but I don’t trust the results with what I’m seeing clinically, and I tell them that – especially when I see way too many pharmacies and doctors.

    It’s a great system, I’ve received calls from other doctors/hospitals and pharmacies about my patients I did not suspect, and have made some calls too. I’m always grateful for the heads up, and occasionally have made treatment plans with other doctors, including who will be the prescribing physician. This has enabled outpatient doctors to have the same information that ER’s have been identifying for years. It would work even better if insurers participated – they’re quick with medication interactions, but never send information about overuse.

    If your state does not have this type of system, they need to establish one ASAP, write your pharmacy and medical boards. We’re not trying to hurt someone in pain or anxiety or with ADHD, we’re trying to identify addiction and diversion. Think of it as identifying the people who are making it hard for you to get the meds that you need and are taking as prescribed.

    As always, it works until someone throws in drugs or alcohol in the mix. Then we need to receive information from the family. (which is not a HIPPA violation, it’s receiving information only – send a letter or leave a voice mail if you want to do it anonymously).

    • annette ciotti

      OARRS is great in some respects. No interface with mail order pharmacies, or with a particular other state approximately 50 miles to my east, though.

      • Sara Stein MD

        I just saw Express Scripts on an OARRs for the first time recently, so hopefully that’s changing.

        • annette ciotti

          That’s good news. I don’t think Caremark is there yet. Now for the great Commonwealth to my east….

  • Suzi Q 38

    My husband’s step MIL was totally addicted to prescription painkillers back in the 90′s. She said that she had severe back pain.
    Due to a divorce, and my FIL’s illness, be analyzed their checking account and spending records. One huge monthly bill was to a pharmacy in their town. We called the pharmacy to see why the monthly bill was about $600.00-$800.00 every month without fail.
    We were confused, because my FIL only drank Ensure, took a couple of OTC vitamins and one antidepressant. Of course, the pharmacy would not give me all of the information.
    I directed the lawyers to subpoena the information from the pharmacy.
    They said that they would not be able to do so as it was privileged information for The Step MIL only. I agreed, then asked them to subpoena just my FIL’s records. I figured once we had that information, we could eventually make an argument to subpoena her records, if his was only a tiny portion of the whole bill. The lawyers reluctantly did so, and the pharmacy made a mistake and sent all pharmacy records for BOTH of them.
    Anyway, it turned out that she was quite an “addict.” She was in her early 70′s, and she had 3-4 doctors writing pain killers for her at the same time. Larger than usual amounts. I bet she was a real “charmer.”

    Anyway, since we had such unsavory information, she was afraid to let the judge or her family know about her problem. She ended up settling out of court for a fraction of what she was originally suing for.

  • Suzi Q 38

    It would be difficult to be a doctor and have to decide who is telling the truth and who is lying. Doctors are not clairvoyant.

    I have had surgeries a few times.
    1. Meniscus repair on my left knee in 1993.
    2. Gyn surgery in 2011.
    3. Cervical spine surgery in 2013.
    4. Meniscus repair on my right knee in 2013.

    I am not sure what I got in 1993 to manage the post operative pain.
    It may have been Vicodin, or something similar.

    For the gyn surgery, it was Vicodin 5/500, #60.

    For the cervical Spine surgery, it was Hydrocodone 10/325 (Norco?) #30.

    For the meniscus repair on my right knee, I told the orthopedic surgeon the truth and said I still had plenty at home. I declined the prescription.

    I recently had to have a molar pulled, so the oral surgeon gave me an RX for Hyrocodone 10/325 #16 (Norco?).

    Anyway, I have about 75% of it left, unused. I must have a fairly high tolerance for pain, or some doctors give this stuff out easily without argument.
    I have to hide it, because I once kept it in a kitchen cabinet and a friend of mine found it. She said that I could sell it for about $5.00 a tablet.
    I didn’t like her comment, so I hid the RX bottles in one of my drawers.
    Ironically, her adult son died of a drug overdose and he was in his late 20′s.

    After my cervical spine surgery, I was in constant pain. It was horrible at night and I also was numb in both my hands and feet. It was difficult to stand and to walk. Sleeping was even more difficult.

    I was just the opposite. I feared getting addicted to these medications for pain. I asked my neurologist to find a different pain reducer than Norco.

    She first put me on Lyrica, and I gained 20 pounds in two months, no kidding. I quit the Lyrica, and then lost weight.

    I asked her to try a tricyclic antidepressant. She thought that was a great idea, so she put me on Doxepin. I knew about the weight gain, but I gave it a try. Same thing…..I had the cravings for carbs and ate a lot.
    I discontinued that and asked if I could try Nortriptyline. We started off on a high dose, but this also caused weight gain. I asked if I could cut the dose in half.
    Believe it or not, the Nortriptyline in lower dosages worked for me.
    I am not 100% pain free, but I am able to function with my duties at home and my work. I am also able to exercise each day.

    I did not gain as much weight with the lower dosages.

  • T H

    None of us WANT to deny people with pain their relief.

    You are correct: it is NOT fair to paint those with chronic pain issues with such a broad brush. It is, however, reality.

    Doctors in private practice actually have it harder than I do: my patients come to me, either willingly or unwillingly. All I have to do is evaluate them and give them my best effort and best medical judgement. Someone else worries about all the overhead, the other staff, and the costs of doing business.

    For someone with a real clinic office, finding that one of the long-term patients is diverting pills, pill shopping, or any of the other myriad forms of mistrust-causing activities is like finding a rattlesnake coiled up in bed next to you when you wake up. In some states, Docs are being held liable for the actions of their patients – in both civil and criminal court. Restriction or loss of licensure is a real possibility as is a lengthy lawsuit. Plus, Primary Care doctors pride themselves on building meaningful relationships with their patients: who likes to find out that the patient just sees them as a way to supplement a drug habit? All this affects the practice: not only the doc, but his staff as well.

    Is it fair? No. Does it happen? Absolutely, because we are no more than human. Though we are professionals, we also have feelings. Being hurt and then learning to protect one’s self has fallout. Should we ‘Rise Above’? as the kids say these days? Yes… but we come back to that human thing again.

    Some of us strive to ‘suck a little less every day’ in a situation where it is constantly two steps forward, one step back.

    The other thing to address is patient expectations: the “pain clinics” are not called “Pain Relief Clinics”. They are called “Pain Management Clinics.” Most chronic pain patients will not experience complete relief from pain. It is a lofty, nearly unattainable goal. Anyone who expects that needs to have a serious talk with their provider about what can actually be done. If total relief happens, fantastic. If it does not, it is the pain management team’s job (and this DEFINITELY includes the patient) to find the patient the best balance between tolerable pain, function, and side effects.