Wednesday, August 13, 2014

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 it:

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.


  1. Would you please publish your view on the article below regarding the number of medical error deaths per year versus the number of narcotics overdose deaths, (both prescribed and street drugs). I believe that the data show fewer than 20,000 deaths per year from drug overdose.

    “In 2010, the Office of Inspector General for Health and Human Services said that bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year.

    Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death, the study says.

    That would make medical errors the third-leading cause of death in America, behind heart disease, which is the first, and cancer, which is second.”

  2. Thanks to David Gittess for pointing out this informative article about Kentucky's legislative response to prescription drug "pill mills" that strikes a balance between curbing abuse and creating obstacles for patients who need pain relief: