Doctors, what's up with this fear of painkillers I see?

Great Debates
1

I took my mom to the doctor yesterday. Long story short, she’s got a spot on her hip. It’s either cancer, a benign tumor or the result of hyperparathyroidism (probably the latter). We’ll know next Friday.

She has a really bad back anyway, but this hip is really bothering her. She’s in a lot of pain and her mobility isn’t too great right now.

So she asks the doctor for a painkiller. Before she can even get the sentence out (literally), he goes:

“I’m not going to give you a narcotic.”

Well gee, she wasn’t friggin ASKING for one!

Then ensued a conversation that has me completely baffled.
He told her what he was going to give her, that it was related to Motrin, which doesn’t work on her. She told him this and he said “I don’t prescribe narcotics.” Note she’s not even freaking asking for a narcotic, just something that will work. I got curious and asked him “How much pain does someone have to be in before you will prescribe a narcotic?” He did a song and dance about how he didn’t think she needed a narcotic and that he likes to try NSAIDS, etc. Then I asked him “what if those didn’t work?” I about fell out of my chair when he replied “I’m not going to talk about that.” (He did later say that he would give her a referral to the pain center here, she’s considering it.)

All she wants is something that will WORK. She’s not fond of narcotics because they make her queasy, but at this point she’d rather deal with that than the pain. He gave her an NSAID that starts with a V and is related to Motrin, I can’t remember the name.

So what is the deal, here? Why do doctors assume that everyone who wants a painkiller is a drug addict? Are they really punishing 99% of their patients due to the 1% who are lying?

This hip thing just isn’t affecting her. It’s putting a strain on me and my family, too. Her quality of life is going down a bit and it hurts all the time. Why would doctors rather condemn a patient to suffering than give them a prescription for something that could help?

It’s not about narcotics. It’s about telling a patient “this is what you can have, and if it doesn’t work, sorry 'bout your luck. We have other drugs but we’re not going to let you have them.”

FWIW, every doctor at this group practice is like this. I can’t believe that these are evil people who want their patients to suffer, so what is the reasoning behind this way of thinking?

2

I’d say that abuse figure is a lot higher than 1%. Speaking from personal experience, any time I see someone under the age of 21 prescribed with a narcotic painkiller, the leftovers are either sold or abused. I’m not saying this is how things are all the time everywhere, just what I see on a local college campus.

3

Okay, fair enough. The 1% was low.

I think we can agree that the addicts are a small minority, though.

4

Well yeah, in comparison to those who use the drugs legitimately, it’s a minority. But it’s a serious problem, and one that you don’t always see if you’re on the legitimate side of the fence.

Not that I’m on the illegitimate side…

I remember the whole OxyContin fad, where I had friends telling me this stuff was presciption heroin–I mean people were seriously into this stuff, and were constantly faking medical injuries to get it. And of course now Rush Limbaugh is in on it too…

Disclaimer: I don’t advocate or participate in drug abuse, nor do I reccommend listening to Rush Limbaugh.

So to summarize, it’s a crazy situation, and because of a few idiots, your mom is getting screwed. I am genuinely sorry and will punch my druggie friend in the head for this. In the perfect world that exists in my mind, your mom would get whatever narcotics she wanted (and so would the druggies) because i’m more of a Libertarian.

5

Addicts may be in a minority in the population, but for many, if not most medical practices, they make up over half the cases of people who come in requesting painkillers.

And docs are in a bind. Many have gotten disciplined for over-prescribing narcotics, others are now getting disciplined for not prescribing narcotics.

Some docs have just decided they won’t prescribe narcotics for anything less than acute trauma or malignant pain. If they document adequately, that practice will usually protect them from discipline. Unfortunately its not always in the patient’s best interest.

I’ve tried my best to be educated on the topic. I spent a week in Cleveland (Cleveland, for gods sake) a few years back just taking an in-depth seminar on principles of prescribing narcotic painkillers. It was complete with lectures by district attorneys, medical examining boards, and Drug Enforcement Administration agents about what does and does not get one into trouble. Unfortunately sometimes what kept you out of trouble with the DEA could get you into trouble with the Medical Board.

It also dealt with trying to decide which conditions merited narcotics. As one would expect, knowing one’s patient is one of the first and best ways to figure this one out.

My principles: Be ready to treat acute traumatic pain (including post-operative pain) with narcotics. Same for malignant (cancer, etc.) pain. Be cautious about treating other pains with narcotics. I try to make sure I know what I’m treating first. Know the patient. Be ready to try other pain-relieving modalities. After thorough investigation, I don’t hesitate to say to the patient “I’m not giving you narcotics” when appropriate.

So I understand where your mom’s doc is coming from. However, I don’t believe its a good policy to declare from the beginning that “I’m not giving you narcotics” unless you already know the patient and situation very well.

I hope your mom feels better!

QtM, MD

6

Maybe this particular group got into trouble for over prescribing narcotics or something.

Were I your mother, I would change physicians so that I could have the security of knowing that I never have to go through needless suffering just because others abuse the substance.

There have been times in my life when I would have done something drastic to myself rather than endure that level of pain.

I hope that everything goes well for your mom.

7

IANAD, but going in and right off the bat asking for pain medication is one of the top red-flag signals that a patient is a drug-seeker. Saying, “Oh, no, that drug (or a similar one) doesn’t work on me” is another. Asking, “Well what if this non-narcotic doesn’t work?” is another. Asking how much pain you have to be in to get narcotics…well, I can’t imagine a bigger red flag.

Let’s face it, there’s an inordinant lot of people in West Virginia who claim to have a whole lot of excruciating pain. The only place I can think of right off with a worse prescription drug abuse problem is eastern Kentucky. Your mother’s doctor sees a whole hell of a lot of drug-seekers, and the conversation you’re describing certainly follows a classical pattern for a drug-seeking visit. I don’t blame him for refusing to discuss the matter any further, really.

Besides, this is probably going to be a long-term sort of thing, and very few doctors like to start a patient on narcotics for something like that. If somebody isn’t already an addict, you certainly don’t want to turn them into one, ya know? A referral to a pain clinic for management of long-term pain is entirely appropriate in that sort of case, especially since your mother also has back problems.

8

Chronic pain sufferer weighing in here.

OK, so saying “X doesn’t work on me” sends up a red flag.

I have run the gamut of NSAID’s, muscle relaxants, and other non-narcotic painkillers. On the whole, I would prefer not to take narcotics because of the addictive potential. Trouble is, the aforementioned non-narcotics don’t work on me. Given the choice between an addiction to painkillers that allows me to function and losing my job because I’m always calling off sick, I would have to say, lay the narcotics on me.

'Course, if I could get a physician’s writte recommendation for medical marijuana (legal here in Nevada), I would not only have relief from my excruciating back pain, but also from my chronic severe (as in frequently suicidal) depression as well, but since MJ is still against federal law, it’s extremely difficult to find a doc that will recommend it.

9

Vioxx?

It’s the “next generation” NSAID.
http://www.fda.gov/bbs/topics/ANSWERS/ANS00956.html

10

When I broke my foot, they gave me Darvocet and I had a very strong, though not allergic, reaction - I have this reaction to anything that contains Tylenol, it’s a general woozy feeling and the smell/taste of a sinus infection… and with the higher than OTC dose in the Darvocet, I had a hard time staying upright on my crutches. I called the doctors and they prescribed Vicoprofin, which was just fine (is there no Darvoprofin?).

Do you think if my foot wasn’t obviously broken (two fractures, one quite ugly) they wouldn’t have listened? If they wouldn’t have given me the Vicoprofin I would have been much more miserable. I offered them the un-used Darvocet and they didn’t want them, so I just pitched the wicked stuff. I probably fit right into the drug-abusing mooch age bracket, too, and I brough my long-haired friend with me to the doctor (because he offered to drive). I don’t knwo what else I could have done to be more suspicious, absent the ridiculously broken foot.

11

IANAD, but going in and right off the bat asking for pain medication is one of the top red-flag signals that a patient is a drug-seeker.

Okay, CCL, I can see your point, however the woman has a sclerotic lesion on her hip and the CT scan to prove it. What does she have to have before she’s justified in asking for a pain reliever? An axe in her head? And why should she accept a painkiller when she has already tried similar ones and knows it won’t work? Seems to me you can’t win either way. Take the drug you know won’t work, call back to the doc’s office and complain and you’re a drug addict. Tell the doc his choice of drug won’t work on you and you’re a drug addict, too. No wonder people in chronic pain kill themselves, if this is what they have to put up with all the time from doctors.

Why he even put her on an NSAID is beyond me. IANAD, but a lesion on the hip isn’t an inflammation of anything. What good is an anti-inflammatory going to do in that case?

12

IANAD either, but I have read that extreme pain actually impairs the healing process. Obviouisly, a patient who gets darvocet or percodan or the like needs to be monitored. That doesn’t mean she shouldn’t be able to get some relief Has she been going to this doctor long? If so, one would hope that he/she knows by now what type of patient she is. Can she get a prescription for just a couple of days’ worth?

In my experience, if Motrin doesn’t work, the Vioxx probably won’t either; they’re in the same family.

13

Ding ding ding! I think we may have a winner. That doc sounds WAY too paranoid.

14

The name of the drug isn’t on Vioxx.

Aha. Found it. It’s Voltaren.

It’s possible they’ve gotten into trouble. This is a HUGE group practice, one of the biggest in the city. Chances are they’ve seen quite a few lawsuits. And the fact the doctor she had before this one did the exact same thing: the “I don’t prescribe narcotics” speech when she didn’t even ask for one – maybe they all got together and created a party line. Maybe they decided it was best some people suffer needlessly than to risk another lawyer hunting them down. (Me? Bitter? They dicked me over in the past, too. I had pleurisy and the Ibuprofen they gave me made me sick as a dog, and they refused to give me anything else … not even another prescription in the same family of drugs. They probably wrote “drug seeking” on my chart, I bet.)

I’m going to try to talk her into taking him up on his offer for the pain center, if it turns out this stuff isn’t working for her.