Doctors and Patients—Treating Chronic Pain As a Team

Doctor and patient together

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.

[Learn more about the science behind opioid use disorder in a free online program from Harvard Medical School, created with support from NIDA.]

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.


Dr. Peter Grinspoon profile photoPeter 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.

 

11 thoughts on “Doctors and Patients—Treating Chronic Pain As a Team

  1. I don’t understand how this ISN’T the way it’s done – especially when a high dose is CLEARLY benefitting the patient. I’ve been stable on approx 1000 MME for over ten yrs. 18 yrs on opioids total. No ongoing tolerance. No side effects. Actually reduced dose by about 1/6th once inflammation from arachnoiditis was treated by Dr. Tennant.

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    1. Thank you for your comment! We’ve got to find a way forward that doesn’t abandon chronic pain patients. That is a really high dose of opiates and a doctor, under the current system, could very well get into trouble for writing a prescription that large. Most would feel uncomfortable prescribing that high a dose as it is out of the norm of what we usually prescribe, but each patient’s needs are different.

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  2. In the 1990s I fell on our deck, herniating 4 discs, causing sciatica and spinal stenosis. I also had a knee replaced from osteoarthritis. My pain was handled with Celebrex.
    In the first 5 years of this century, I was diagnosed with RA, osteopenia, degenerative disc disease, & facet joint syndrome. I broke my left arm twice, and my right arm once. I was put on methotrexate, and steroids: both pill form and in shots in my back. I also had radio ablation done. My pain meds were increased first to Vioxx, then to Ultram, then to a low dose of oxycontin. I didn’t like the oxycontin, due to the dizziness it created, plus the roller coaster effect of pain relief, then pain again before the next pill. I addressed it with my pain doctor who then put me on Fentanyl.
    My diseases progressed over the last 13 years, and so did additional injuries. I was diagnosed with interstitial cystitis, which is very painful. I fell in the kitchen, breaking my hip which needed replaced. The doctor put in the wrong size, so it (VERY painfully) dislocated twice, resulting in another replacement. I fell off of the porch resulting in breaking my arm in 18 places (including a spiral break from wrist to elbow). They called in a retired surgeon so they wouldn’t have to amputate it. The arm has 3 plates and hurts all the time. Same accident broke my pelvis in 2 places. My fentanyl was increased, and they added an IR Norco. The same year as the porch fall I fell in our home, fracturing 2 vertebrae, and crushing 2 others. I also broke my pelvis again.They put cement in the vertebrae, but I am still very severely hunched over.. For the past 6 years I have been on 150mcg Fentanyl and 7.5mg Norco (200/month). This dosage allowed me to walk with a cane instead of a walker, to bathe myself, to attend church, and socially interact with my family. When I heard about a spine stimulator for pain *I* asked about getting one, because I’D LOVE TO BE BETTER! They tried a trial and it helped…BUT I WAS STILL ON THE PAIN MEDS.
    In May, they plan to put the “permanent” stimulator in. I put that in quotes, because I know there is a significant failure rate. Then, one week later they intend to take away my current pain medication, and put me on buprenorphine. They haven’t told me the dosage, but the strongest one has a morphine equivalency of 1/10th of what I’m CURRENTLY on! Then….they intend to taper THAT!! Down to NOTHING. I have always thought my PCP was a fabulous doctor. In fact, about 8 of my friends go to him based on my recommendation. I held my pain doctor in high regard, too. My pain doctor wouldn’t look me in the eye when he was telling me the switch. When I went to my PCP to see if it was true, he said their hands were tied. We could tell he was upset. He kept apologizing..
    It makes me angry that the CDC panel that recommended this nonsense was stacked with anti opioid doctors. There was not ONE pain doctor in the bunch!!

    MOST IMPORTANTLY – what do we do with the statement from the FDA dated February 15, 2018 which states: Annually approximately 100 million people in the United States suffer from pain and 9 million to 12 million of them have chronic or persistent pain, while the remainder have short-term pain from injuries, illnesses, or medical procedures. All of patients in pain should benefit from skillful and appropriate pain management, which may include the judicious use of opioid medicines in conjunction with other methods of treatment or in circumstances in which nonaddictive therapies are insufficient to control pain. Clearly, though, more research on pain control is warranted. The FDA applauds the work done by the U.S. Department of Health and Human Services and the entire Interagency Pain Research Coordinating Committee to further efforts to encourage more research and awareness of the management of chronic pain. We are also working with NIDA to encourage the development of nonaddictive pain medications.

    We treat our ANIMALS more humanely than this!! Doesn’t ANYONE have the power to stop it??

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    1. A lot of people, doctors included, are concerned that the pendulum is swinging too far in the other direction, away from using an adequate amount of opiates to treat people with chronic pain. Hopefully, we can settle on a “middle path” that avoids what we did 2 decades ago, putting too many people on opiates, and what we are doing now, being forced to force people who seem to need opiates off of them…

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  3. Finally a Physician who has knowledge and knows rhe True Issue AND has an acceptable plan!

    The plan of being “Grandfathered in” would be grest, but what about those of us, (like me) who have already been forced to make an abrupt taper down from (175mcg q 48 hours – that I have been on for 3 years) and in 1 days time RIPPED down to 75mcg q 72 hours? (I tried every kind of treatment, the first 2 years and nothing worked…so then then next 12 years ive been on fentanyl (Started on 25mcg, but over 12 years obviously developed a tolerance).
    I used to have a LIFE, I used to be an ER Nurse, but then became partially bedridden (70%) about 1 year ago then on February 6, 2018….my life changed from partially bedridden to 100% bedridden, depressed, developed social anxiety (I dont even want to leave my bedroom). The only time I do leave my bedroom is when I am FORCED to..to go to a Dr. Appt. Because I know the pain will be so great, and it will take days to “calm my body down”… Its hardly worth even going to the dr anymore. Between my herniated discs, my 3 back surgeries, my RA, my Lupus, my ” unknown and unnamed additional autoimmune disease that now im supposed to go to the medical school and be a guinea pig to find out what else is wrong, to fibromyalgia, and on and on…Im so done with this. We need help. I need help. I need at least some of my life back. If the Grandfather policy were to take place, I doubt they would ramp me back up from 75mcg to the 175mcg that I WAS on (and I dont want them to!) But at least give me something for breakthrough!! It is so inhumane what they are doing! I went to see my pain mngnt Dr of 13 years just last week (It was the 1rst appt. Since forcing me to abruptly tsper down and experience withdrawl)..well you would think he would care about how I was doing…RIGHT. Since Feb. 6th, he hired a NP, so ge doesnt have to deal with us anymore. He only sees new patients now (after 13 years, 3 surgeries, over 2 dozen epidurals, and hundreds of trigger point injections), and now he wont even face me after the HELL he has made me go through…so inhumane, so wrong..the damage is done…now what???

    Silently Screaming

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    1. When I suggested “grandfathering” people in, I’d hope it would mean, retroactively, helping people who were tapered against their will, and who are suffering and doing poorly, so they can once again, live their lives…

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  4. Grandfathering patients already on high doses is a great idea as is using caution when prescribing for new patients. Great article.

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  5. I would like to say not all patients that are prescribed opiates get addicted. I have been taking opiates for probably 15 years. I do smoke medical marijuana, and for that reason I think is why I have not ever got addicted to the pain medicine I need it for my pain level but it doesn’t make me sick if I don’t have it and I have never ever taken it any more than what I’m supposed to and my doctor is tapering me off in a couple of months at my choosing and I choose to use marijuana instead of the pain medicine now like I said again not all are addicts but the addicts are the ones that have ruined it for us. Too many Overdosed. There are some people that actually do need it and we take it as we are prescribed and if you do that you don’t get addicted that bad as far as I know. These are my reasons I have chronic pain.
    I have rheumatoid arthritis and I Have Diabetes Type 1 have diabetic nerve pain and I have fibromyalgia. I have chronic pain each and every day of my life but now I’m going to use Voltaren gel and Tylenol and of course my rheumatoid meds I have been on all along. If I didn’t have medical marijuana I would need nerve medications for anxiety. My Dr is a good Dr and his hands are tied.

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    1. Thanks for sharing your story with us, Bobbie. Opioid use disorder is certainly an important issue to address, but it is also important to give voice to stories like yours. If anyone would like to learn more about the current opioid crisis, how we got here, and what can be done to solve it, Harvard and Harvard Medical School are offering free online resources.

      If you are a layperson, learn more at: The Opioid Crisis in America (https://www.edx.org/course/opioid-crisis-america-harvardx-hhp100-0).
      If you are a health care professional or social worker, free CME is available through: The Opioid Use Disorder Education Program (http://direct.externaled.hms.harvard.edu/hga/oudep/overview?utm_source=BMC_OBAT&utm_medium=website&utm_campaign=OUDEP_affiliatelink).

      We appreciate your getting involved, Bobbie!

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    2. Thank you for sharing your story. I agree that not all patients that are prescribed opiates get addicted; in fact, it is only a very small percentage that do. I’m glad that you have found a regimen for your pain that works for you. The doctors are doing their best, but, as you know, this is a complicated issue for everyone involved!

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