When pain management goes right

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My eyes flitted down to the electronic medical record in front of me. I was conducting a physical assessment of a patient new to my clinic and the area. The forty-five-year-old male sat down before me, and I noticed immediately that he was morbidly obese and sweating profusely. I tapped away as he rattled off his various diagnoses which included: cervical radiculopathy, depression, chronic low back pain with radiculopathy, and insulin-dependent diabetes, to name a few.

I reviewed his medication list and immediately noticed the prescription for oxycodone. For the second time that day, I patiently explained that I would need his prior medical records, a urine drug screen, and a signed controlled substance agreement prior to prescribing any controlled substance. Expecting anger, frustration, impatience, and indignation over accusing him of inappropriate use, I was instead met with ready compliance. It was such a surprise, and it warmed my heart. My patient congenially stated that it would be fine. He was one of the few patients that had set up an initial appointment soon after moving, as he knew the snail’s pace at which the medical system runs. Knowing that medical records can take months to work through health systems, I prepared myself for the long wait for his medical chart. With the extra time I offered him osteopathic manipulative therapy, which he accepted. It was able to reduce his pain by a few points in his neck and low back. I was ecstatic to avoid the compulsory twenty-minute lecture on tolerance, escalation, and dependency to narcotics and actually spend my time focusing on pain management.  I refilled his non-controlled medications and scheduled a follow-up appointment in six weeks. I also ordered a urine drug screen. I make a point of being very strict about narcotics.

I experience scenarios like this at least three times per day, sometimes more. I expect that it will become more frequent, especially as the number of Americans on controlled substance rises and the expectation is to be chronically maintained or escalated despite changes in age, functional ability, and drug interactions. While steps are being taken to avoid dependency, no efforts have been made to address the underlying misconception that a tablet can solve a patient’s problems. Direct marketing, along with physicians uneducated to the current standard, has lead to this public health nightmare. A nightmare that plays out in office rooms across the country as patients demand sedatives, hypnotics, opioids, and stimulants without realizing the long-term effects. These demands contribute to physician burnout and lead to emotional exhaustion, depersonalization, and a sense of low personal accomplishment.

Six weeks later and no closer to obtaining medical records, my patient hastily handed me a patient summary note from his previous pain management clinic. It corroborated his diagnosis and verified that his medication dosage was appropriate. This clinic was in another state and I had no way to review his controlled prescription history.  I couldn’t help but reflect on the ineffective regulations for statewide prescription drug monitoring, especially in areas where state lines are a mere stone’s throw away. I looked up at him, clearly in pain and sweatier than usual. Since his last urine drug screen was consistent with his current medications and I had some semblance of a medical record, I refilled his last oxycodone prescription and had him plan to follow up at our local pain clinic to get surgical intervention.

As I was finishing up notes from earlier in the week, a nurse poked her head in and alerted me that a counselor at a drug rehabilitation facility would like to speak to me concerning my patient. Startled, I picked up the phone to hear that my patient had met with a counselor to discuss his feelings of opiate addiction and suicidal ideation. He notified me that my patient had been checked into a drug rehab facility for snorting heroin in the past and was concerned he would start using again. Horrified by this realization, I felt shamed by my inappropriate prescribing. I emphatically told the counselor that I would not be prescribing my patient any further narcotics and that the remainder of his prescription would be tapered.

My heart was in my throat. How had this patient slipped through my stringent system? How had I failed to screen appropriately? The controlled substance agreement was a stack of paperwork detailing mental health, prior abuse history, and a series of agreements between the patient and myself. My patient had lied to my face and manipulated me into providing him something that could kill him. I felt betrayed and terrified that I had so easily been complicit in my patient’s twisted addictive spiral. My compassion and sense of humanity had backfired spectacularly. Dark thoughts swirled in my mind, making me wonder as to the competency of my medical training which failed to prepare me for the depth of patient diversion, misuse, abuse, and noncompliance. The experience led me to a state of hypervigilance and feelings of unwarranted mistrust toward my other patients.

Two weeks later, my patient returned to my clinic. My anger and frustration had welled up. I dread these types of visits. Visits during which I spend the majority of the time drawing a picture of the neuromuscular junction and explaining why I cannot prescribe scheduled substances to them. My patient explained that he was in constant pain and had only snorted heroin a few times over a year ago. He demanded medication to assist with his pain control, and I calmly stated that I could only treat with neuropathic agents. I empathized with him, and though I understood that he was in legitimate pain, I would not treat him with narcotics due to his history of abuse and the potential risks. After a thirty minute conversation, my patient walked out, muttering angrily and threatening that he was either going to the emergency room or would find something off the street. His comments only added to the overwhelming emotional fatigue that I felt about whether I was even making a difference by standing up to the wave of addiction moving through the community. I sighed with a heavy heart but mentally prepared for my next patient. I tended to be strict about illicit drug use.

I read through messages from my patient in the electronic medical record. After three months of waiting, he was finally placed in a rehabilitation facility in another state. Most local community resources are completely overrun when it comes to the management of pain or mental health. I perused the affiliated hospital records to check if he had been to our emergency department. He had not. I spotted a nurse’s note stating that he had successfully completed his sixty-day stay and had scheduled a follow-up appointment with me. As I walked into the small room, my patient was seated calmly. I congratulated him for completing his time in rehabilitation. My patient smiled and happily expounded on his extensive time there. He relayed how he had wanted to get narcotics at the emergency room, just like he had threatened during his last visit; however, he resolved not to do so since I had refused to give him a prescription for oxycodone. He stated that his mental health had finally stabilized after extensive time in rehab and that he received the counseling help that he had needed. After increasing his non-narcotic pain medication and completing the visit punctuated with my delighted congratulations, my patient stood up and a little sheepishly asked if he could hug me. My arms were as wide as my smile. I am strict about hugs.

Sheila Ramanathan is a family physician. This article originally appeared in the New York State Academy of Family Physicians’ Family Doctor.

Image credit: Shutterstock.com

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