Opioid Prescribing for Dummies

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We marginalize people in pain to the point where shooting up black tar heroin under a freeway overpass makes the most sense to them.
We marginalize people in pain to the point where shooting up black tar heroin under a freeway overpass makes the most sense to them.

First, they tell us we're not treating our patients' pain sufficiently. We are encouraged — nay, exhorted — to do a better job at it.

Then they tell us we're treating it a little too well.

It seems that every few years, the opinion pendulum swings one way or another regarding opioid prescribing. But the latest swing of that sharp-bladed pendulum is threatening to cut off the heads of doctors who are a little too generous with narcotic pain relief.

The treatment of pain in America has become politicized.

Consider the facts, and you'll quickly see why all of this leaves doctors on the front lines of patient care baffled, perplexed and dumfounded — in a state of stupefaction.

We need some guidelines to help us along. We need Opioid Prescribing for Dummies. Here are a few excerpts:

1.       Pain Is Real

Over 100 million Americans suffer from chronic pain, according to UpToDate. And at least half of them show up in my clinic daily. Ha!

But seriously, America is racked with pain. Our appetite for opioid pain pills is gargantuan. According to the American Society of Addiction Medicine, in 2012, 259 million prescriptions were written for opioids. Sales of these pills have reached an all-time high — pun very much intended.

But pain is real. Forget about the obvious, much maligned “drug seekers” for a moment. Most people wanting opioid prescriptions are indeed in pain.

The pain comes in all different shapes and sizes, but some of the most common presenting maladies are chronic back pain, chronic knee and shoulder pain, migraines, fibromyalgia, complex regional pain syndrome (whatever the hell that is), interstitial cystitis, dental abscess/cracked tooth and pelvic pain/vulvodynia.

Sure, doctors have led some pain patients down the wrong path. Narcotics cure nothing. And the literature tells us that people who take narcotics regularly require more and more of the drug to achieve the same level of anesthesia or pain relief.

But this doesn't refute the fact that pain is real and some people need narcotics for their pain. Indeed, many can't take NSAIDs due to past histories of bleeding ulcers or renal compromise. Others find that ibuprofen and other NSAIDs or Tramadol “just don't cut it” for managing their level of pain — which is always greater than a “12” in my experience.

So, the pain is real. And it's not realistic for the government to try to legislate pain control by dangling that previously referenced sharp-bladed pendulum right in front of us.

2.       Doctors Are Busy, to Say the Least

A quick review of the literature will show that doctors are seriously overburdened. Call it “burnout,” call it abuse, call it whatever you want, but few people in their right minds would say that doctors are slacking these days. Nor would anyone dispute that doctors are treating dramatically increased numbers of patients.

The corporatization of medicine in the US has seen to that.

Do we really have the time, while we are knee-deep in clinical problem solving, to look up every single patient on a website for controlled substance prescription monitoring? Should we be suspicious of anyone who presents with pain, even those with obvious shingles or displaced fractures sticking through their skin?

And who gets to make the rules for what gets treated with a narcotic pain medicine versus a topical rub or a trip to the corner chiropractor?

While evidence-based medicine does provide us with some good guidelines, we doctors must always remember that no two patients are alike and that “one-size-fits-all cookbook medicine” is something to be feared and eschewed by anyone who has taken the Hippocratic or Osteopathic Oath.

3.       Blame the System, Not the Pills

There are far too many people in the United States dying from narcotic drug overdoses — 78 people a day, says our Surgeon General.

But a closer look at the facts shows what's really killing these folks. It's elephant tranquilizers, fentanyl masquerading as heroin or long-acting opioids being inappropriately used.

We have a system that treats people in pain, especially people in pain needing narcotics, like pariahs. We marginalize them to the point where shooting up black tar heroin under a freeway overpass makes the most sense to them. Legalizing opium dens would be safer.

Hey, I don't know about you, Doc. But I know my pain patients aren't dying from opioid overdoses.

How can I tell? Because they keep coming back to see me — over and over and over again.

No stupefaction there.

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