In a recent article for Pain Medicine News, “4 Steps Every Provider Must Take Before Prescribing an Opioid,” two lawyers detail the voluminous documentation doctors must collect and maintain to protect themselves against all these new anti-opioid rules.
When even so many doctors don’t understand chronic pain, it’s no surprise that lawyers don’t either. They are trying to fit the practice of pain management into a legal framework to defend themselves from legal trouble, but these efforts lead to absurdities, like:
“The treatment plan should include an end strategy for treatment. A practitioner must monitor the patient’s progress in treatment and toward meeting the treatment goals.”
What possible “end strategy” can there be for a chronic lifetime condition? If no treatment should begin before an “end strategy” has been formulated, it would be impossible to treat diseases like ALS, MS or even diabetes.
When a doctor has determined that a patient’s presenting symptom doesn’t have a known cause that can be addressed, like chronic idiopathic hives or chronic pain, for instance, the primary goal becomes to relieve the symptom, itch or pain, which can be accomplished with medication, like antihistamines or opioids. No one would suggest that a patient be left to suffer a lifelong relentless full-body itch without medication, yet no one has qualms about leaving the equivalent relentless pain unmedicated.
Treating a patient’s distressing health symptoms with prescribed medication is an unquestioned intervention in any other area of medicine, like diabetes (goal is “control blood sugar,” accomplished by insulin) or high blood pressure (goal is “lower blood pressure,” accomplished by various antihypertensive medications).
Even erectile dysfunction is considered a “medical issue” deserving palliation with a medication (goal is to “achieve an erection,” accomplished by Viagra).
But when dealing with the medical issue of chronic pain …
Then the usual norms of medical care evaporate, replaced by either outright disbelief and suspicion or diversion: the diversion of patients from an effective treatment to various less effective and even unproven “alternative” treatments with many more and potentially damaging side effects.
So pain patients are prodded through a long series of trials of medications or therapies much less likely to be effective. This often includes repeated risky steroid injections and even surgeries, like spinal fusions. Unlike drugs, orthopedic surgeries can be sold to the public before they undergo any rigorous testing to ensure they are safe and effective. Only after months or years of treatment failure and increasing, pain are these patients considered worthy of proper medical pain management with opioids.
This cruel indifference to a patient’s distressing symptoms and iron-fisted determination not to prescribe opioids is a shocking departure from medical norms.
Imagine an overweight patient with dangerously high blood pressure.
These days we have several effective medications to lower it, though non-drug solutions are always preferred. So the patient would be encouraged, cajoled and even pressured to 1. eat a lower calorie healthy diet, and 2. get more exercise.
But, what if the patient is not exercising enough and not limiting their diet enough to lower their blood pressure by these means over several months?
Perhaps this patient is non-compliant?
Not a problem.
The doctor just surrenders to the inevitable and prescribes an effective medication instead. Afterward, the patient is periodically monitored and the medication adjusted to keep their blood pressure within safe ranges. This is how the medical management of a chronic condition is supposed to work.
Diet and exercise may never be mentioned again.
But, what if you have debilitating chronic pain from, for example, a hopelessly unstable spinal column due to Ehlers-Danlos or iatrogenic “Failed Back Surgery Syndrome?”
First, the doctor tries non-drug lower-risk therapies. Perhaps an appropriate exercise program designed for you by a physical therapist. Or maybe some sort of occupational or movement therapy to adjust how you use your body in daily life or even an “alternative medicine” therapy you may have found helpful in the past.
But what if your intractable pain remains debilitating leaving you unable to exercise, get restorative sleep or fulfill the “activities of daily living” (which is what makes your pain so debilitating in the first place)?
Still unwilling to start opioid therapy and now reaching for long-shots, the doctor wants you to try various non-opioid medications. These generally fall into two categories, the tricyclic antidepressants and antiepileptics, like gabapentin or the ever-popular (and obscenely profitable for Pfizer) Lyrica.
These “dirty” drugs (with many nasty side effects) were created for other medical issues and must be prescribed off-label because they have only been proven to alleviate very specific kinds of pain (neuropathic, fibromyalgia) for specific patients. Yet these drugs are now routinely prescribed for all pain patients.
It seems that anti-opioid advocates have no problem with our use of all kinds of minimally effective, unproven drugs as long as they are not opioids. That fact alone seems to confer upon these drugs a blanket blessing and has spawned countless studies trying to force positive findings on ambivalent results.
But what if you find these drugs aren’t effective for you (as they aren’t for the majority of patients), while the side effects leave you even more exhausted and dopey and hungry all the time?
Then after months of doctor appointments and therapy sessions, after so many multi-week rounds of so many different medications with so many side effects, all to no avail — only then is your doctor “allowed” to prescribe opioids.
According to lawyers, this is the progression that pain doctors are required to document for each one of us, even at every visit (no wonder doctors use the cut and paste function of EHRs so much).
Threatened by the seemingly unlimited powers of the DEA, doctors can no longer treat chronic pain as they do all other chronic conditions without interference from law enforcement and other non-medical government agencies, swayed by media hype more than science.
The “war on drugs” — misdirected to focus on essential medications instead of illicit drugs — has done nothing to treat addiction or stem to flow of illicit fentanyl feeding the “overdose crisis.”
Instead, its main accomplishment has been to impose arbitrary restrictions that interfere with the medical management of a chronic condition, leaving pain patients in agony while the number of people overdosing on illicit street drugs relentlessly increases.
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