By Peter Grinspoon, MD
March 8, 2018
[Part two of a three-part series.]
Why do so many healthcare providers find it difficult to treat chronic pain patients? I have not seen colleagues roll their eyes or audibly groan upon hearing that a patient that is new to their panel has diabetes or cancer, so what is it about a pain patient on opiates that fills so many with dread?
To start, most of us are perfectionist, type-A personalities and we dislike doing things poorly. To say that the training we received in managing chronic pain was inadequate is an understatement. Medical schools are just now starting to educate physicians about the complexities of treating pain. There are many nuances to this topic, such as the benefits and dangers of opiates, alternatives to opiates, both medical and nonmedical, and the parallel issues of dependency and addiction. Gone are the days of “take two aspirin and call me in the morning.”
It is also very difficult to tell who is really in pain, and how much pain they are in. There is no “painometer” that can measure this. Because opiates can cause such euphoria, are addictive, and have black market street value, we are wary of “drug-seeking patients” who exaggerate their pain. Early into my medical career, I actually followed a patient out into the parking lot and, hallelujah, his limp was cured once he thought that no one was watching him. I wanted my prescription for Percocet back, but felt it would have been inappropriate to ask. It was the last one he received. When patients take advantage of you it hurts, and you feel as if you have failed the patient, the system, and yourself.
Then there is the hassle factor. Most of the conflictual encounters I’ve had with patients have been over opiates in one way or another. One patient threatened to “come over with a gun” if I didn’t get his Percocet prescription ready soon enough. (In this case, I had even said yes to the prescription, he had just wanted it right when he called, not in a few hours.) Due to the DEA, the medical boards, hospital policies, and insurance companies, the red tape involved in taking care of patients on opiates can feel like something out of a Kafka novel. We have to manage drug screens, pill counts, opiate contracts (all of which are degrading to the patients), prior authorizations, and threats to our licenses, if the medical board or the DEA think we are prescribing too liberally.
All of this is profoundly time-consuming, time which we might have had a generation ago, but which today’s burnt-out, rushed, harried doctors can’t afford to spare given the dozens of other things we are responsible for in the twenty-minute spots we have to care for each patient.
We find ourselves in impossible situations. What if the patient gets addicted? Aren’t we contributing to the opioid epidemic? What if a patient on opiates loses a prescription? How do we know that is legitimate? I’ve had patients apologize to me later, when in recovery from an addiction, for doing exactly this (i.e., pretending to lose the prescription and then selling the extra pills). What if they test positive for cocaine? Then, it is too dangerous to continue to prescribe, but if we stop prescribing, they likely will withdraw, and may be forced to buy street drugs, which can be lethal. Either way, we can be sued. For that matter, we can be sued for treating someone’s pain, if there is a bad outcome, such as an overdose; and we can be sued if we don’t treat the pain, for abandonment, if we decide that a particular patient is just too risky to maintain on opiates. It can feel as if we just can’t win.
None of this, of course, in any way discharges us from our obligation to treat chronic pain patients to the best of our ability. They are suffering. It is not their fault that “a few bad apples” are disruptive in the office or that the government and the insurance companies are making it increasingly onerous to prescribe opiates. For the millions of chronic pain patients in this country who are merely trying to find a way to live their lives, despite the crippling pain that limits their activities, we are their doctors, and it is up to us to find a way to navigate, to barge through, or to ignore the obstacles we face in treating them. They deserve to be treated with the same expertise and care that we apply to all other chronic conditions. We are their advocates. The buck stops here.
The first part of this series, “The Orphaned Patient” discussed the plight of chronic pain patients who feel abandoned by the medical profession and left to suffer in agony. This piece, “The Harried Doctor” attempts to shed some light on why the doctors are fleeing from their responsibilities to treat chronic pain. The concluding piece will attempt to synthesize these two perspectives and perhaps help both sides forge a way forward.
Peter Grinspoon is the author of the memoir Free Refills: A Doctor Confronts His Addiction. He currently practices as a primary care physician at an inner-city clinic in Boston, is on staff at Massachusetts General Hospital, and teaches medicine at Harvard Medical School. He spent two years as an Associate Director for the Physician Health Service, part of the Massachusetts Medical Society, working with physicians who suffer from substance use disorders.
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