Friday, December 5, 2014

Know the problem of 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

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.


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