First do no harm.

Treat every patient with respect and dignity.

These are values I try to live by and incorporate into my daily work.  Treatment of chronic pain is the scenario that puts me and every practicing primary care physician in a no-win situation regularly in the office. To try to make physicians feel more comfortable treating pain most states have tried to legialate guidelines.  They have been less than reassuring.  In Washington all I have to do to comply with the guidelines is to follow a comprehensive 4 page list of recommendations. Washington is helpful by also legislating recommended responsibilities for patients.

For physicians they state: “Subjective reports by the patient should be supported by objective observations.”

For patients they state: ”The patient should demand respect and expect to be believed.”

How the physician can be expected to “believe” the patient, yet not rely only on subjective history by the patient but have objective evidence often for problems where no objective evidence exists, is the inherent flaw in trying to define and regulate pain management.

Add this to the environment in which we practice.   Each week for the last three weeks I’ve had a young male, ages between 21 and 25, present to the office asking for help in one way or another for addiction to Oxycontin.  In each case the patient had never received a prescription from a physician for an opioid.  Each time they had taken the drug first when supplied by a friend or coworker, either for treatment of pain from a minor self-limited problem, or for recreational use.  Each time there was a quick progression, over weeks to months, from occasional use, to regular use, to daily use and addiction.  So far in each case, thanks primarily to supportive parents and patients with a strong desire to get treatment, I’ve been able to aim them towards a treatment facility where they could get help.  I’m not a naïve or casual observer of the current prescription opioid epidemic in America.

I’ve posted several times on this and related issues: Can’t find a doctor to prescribe pain meds? and Oxycontin: What’s the big deal?

Still I continue to be amazed at how readily available Oxycontin has become for recreational use.  This is a medication that is a Schedule 2 controlled medication, meaning to get a prescription you need to have a written prescription on forgery resistant prescription pad paper, and cannot get a prescription with refills.  Despite these attempts at preventing abuse, the drug seems to be easily available for abuse. To add urgency to this problem is fact that accidental overdose from prescription opioids is at epidemic proportions.

Without any doubt the posts on DrPullen.com that have had the most interest have been the posts on pain management.  The most passionate comments have been from patients with chronic pain who feel that their need for opioid management of their pain is underestimated, undertreated, poorly understood, and that they are treated without compassion or respect.  Unfortunately some of them are right, but the incredibly widespread abuse of prescription opioids at this time puts physicians in an impossible position.  We are supposed to both show compassion and adequately treat non-malignant pain with the same drugs that professional patients and opioid abusers seek to get prescriptions.  All this is in the face of treating a condition, pain, for which there are only subjective scales to quantify and for conditions which often are diagnosed strictly on what the patient tells us, without any objective evidence of their existence in a given patient.

You could compare this to being asked to look at a young person and sell them alcohol based on their general appearance to decide if they are 21 or not, and if you guess wrong, having the possibility of being punished for wrongly selling to a minor.  There is no state authorized ID card to tell us which patients who look like they have pain from fibromyalgia, interstitial cystitis, peripheral neuropathy, lumbosacral disc disease, or lots of other conditions.  We are simply left to do our best to make a good judgment.  Patients are just left in pain.  This whole scenario stinks.

I’m not alone in struggling with this dilemma.  An FDA policy called REMS (Risk Evaluation and Mitigation Strategy) for opioid prescriptions has been a unique approach to addressing this problem. The complex issues related to this policy are nicely discussed in a Pharmacy Practice News article for those of you interested in the details of this debate, but the bottom line is that no one has figured out an approach for the prescribing physician to use to confidently use opioids to help patients manage pain without inadvertently being deceived into prescribing opioids to those patients seeking drugs to sell or abuse.  It’s unlikely that regulations and legislation will provide helpful tools to address this mess.

Most physicians have become really defensive in response to this difficult if not impossible situation. In Pierce County, WA, where I practice, it is nearly impossible to find a primary physician willing to accept a new patient who requests continuation of prescriptions for significant quantities of opioids for pain management.  It’s a shame that we have reached this impasse in care of pain in our country.

Edward Pullen is a family physician who blogs at DrPullen.com.

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