By Peter Grinspoon, MD
April 5, 2018
[Part three of a three-part series.]
As a profession, we can best navigate this complex thicket by returning to a basic, simple principle: the patient comes first.
As an undergraduate philosophy major, I learned that a moral system was flawed if a situation could present itself where a person could do no right. When it comes to providing pain medications, and treating chronic pain patients, doctors can feel as if their moral universe is broken. We are assailed on all sides. Bureaucrats try to restrict our prescribing and intimidate or harass us into not prescribing opiates. Patients rage at us when we can’t or don’t prescribe these medications. The end result can be a rupture in the thing that most of us value above all else: the doctor-patient bond.
A good deal of the problem is that physicians are caught between two competing agendas: combating the opiate epidemic by curtailing the overprescribing of opiates and treating the chronic pain of people who, for better or worse, currently rely on opiates to alleviate this. Each of these agendas is further complicated by inconvenient facts such as the continuing rise in opiate overdoses despite a drop-off in opiate prescriptions, and the emergence of new studies questioning the efficacy of opiates for chronic pain. Hundreds of lesser agendas are also muddying the water, by entities such as the DEA (which can persecute doctors), the CDC (with overly strict guidelines), PROP (a group of anti-prescribing enthusiasts), the medical boards (jumping on the anti-opiate bandwagon), the insurance companies (exploiting the opiate crisis to avoid paying for anything; limiting the time doctors and patients can spend together), hospitals (make trained pony doctors jump over hoops), Big Pharma (exploiting this issue any way they can), etc. The list goes on.
As a profession, we can best navigate this complex thicket by returning to a basic, simple principle: the patient comes first. Of course, if the DEA is breathing down your neck, and the medical board is threatening to yank your license because you are prescribing a high dosage of a particular opiate for a particular pain patient, few would fault you for backing down, especially if you have a family to support. Yet, over time, we must find a way to reconnect with our patients, and remove all of these third-party interests from distorting the sacred trust between doctor and patient.
Much talk has been dedicated over the last several decades to the concept of patient autonomy. Perhaps, in an age where our physician sisters and brothers are burning out from an onslaught of Orwellian insurance restrictions and soul-destroying electronic medical record systems, a bit of thought should also be given to regaining physician autonomy. As this relates to chronic pain patients, we can’t let ourselves be bullied into not treating our patients’ pain. We need to be empowered to decide, together with our patients, what is the right course of action.
It is true that opioids have been vastly overprescribed, and in my time as a primary care doctor, I’ve seen many patients on chronic opiates who never should have been started on them in the first place. Yet, that doesn’t give us the right to abandon them or to taper them against their will. We need to listen to their concerns and, after explaining the risks and benefits, provide them with the pain relief they expect and deserve. For their part, they need to understand why we sometimes can’t continue their medications, and they need to listen to our explanations with an open-mind. In many cases, they may not be able to hear us, as was the case with a recent patient who continued to test positive for cocaine, so that continuing to prescribe opiates was just far too dangerous. He threatened to sue me, to report me, and to bring a pox on my future generations, etc., but I was doing the right thing.
The concerns that painkiller overprescribing is contributing to the opioid epidemic are not unwarranted. A majority of people start their prescription painkiller addictions by obtaining pills from friends or relatives who had extra unused pills sitting around. It stands to reason that, with fewer pills circulating, there would be less exposure, less diversion, less of a black market, and less addiction to opiates in the future. (Of course, many people first encounter opiates with heroin, and clamping down on prescribing does nothing to prevent this.) But we can’t let an over-zealous approach to one crisis precipitate another crisis and, increasingly, stories are circulating of chronic pain patients obtaining street drugs, which are far more dangerous, or even committing suicide in pure desperation, because their pain is no longer being adequately treated by their doctor.
Perhaps a humane way forward is to “grandfather” in those patients who are currently on high doses of opiates. It is not their fault that they were started on such high doses and they shouldn’t be persecuted in a rush to limit pills. We can offer them voluntary tapers, and educate them in detail about the risks of high-dose opiate treatment, but if they decline, and there aren’t any absolute contraindications, their opiate supply should be maintained.
In contrast, with new chronic pain cases, opiates should be used only as a dire last resort, after all the other options such as physical therapy, Tylenol, NSAIDS (which are also very dangerous), injection therapies and medical cannabis (which has been vastly over-pathologized and underutilized) have all failed.—
In the meantime, physicians should push back against unreasonable restrictions on our prescribing and on our ability to practice. We ought to once again decide for ourselves what is right and what is wrong and we must try to rededicate ourselves to establishing and maintaining the primacy of the doctor-patient relationship. Perhaps this can even be a first step toward rejuvenating our broken medical system and rediscovering the joy and art of a life dedicated to practicing medicine.
The first post 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. The second post, The Harried Doctor, shed some light on why the doctors are fleeing from their responsibilities to treat chronic pain. This final piece attempts to synthesize these two perspectives and perhaps help both sides forge a way forward.
Your opinions are valuable to us. Sharing your own thoughts and experiences in the comment section below will help us move closer to a common understanding.
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.
Follow Dr. Grinspoon Twitter: @Peter_Grinspoon
Subscribe to the Harvard Health Publishing newsletter for addiction and recovery information: Breaking the Cycle
*OPINIONS EXPRESSED BY OUR GUEST AUTHORS ARE VALUABLE TO US AT LEAN FORWARD, BUT DO NOT REPRESENT OFFICIAL POSITIONS OR STATEMENTS FROM HARVARD MEDICAL SCHOOL.