Pain and Narcotics: Physicians in the Crossfire

Associated Press reports an increase in the use of narcotics across the United States.

Narcotic use has nearly doubled over the last decade, but illegal diversion is now landing physicians in jail! A recent New York Times Magazine article shed light on the case of one physician who went to jail for 30 years for what some people suspect may have been poor-record keeping. Some jurors commented that he should have known the drugs were being diverted because the doses were excessive.

Unfortunately this flies in the face of medical and scientific knowledge that the effective dose of a narcotic can be affected by physiologic habituation. The quantity of drugs the jailed physician prescribed were well within medical standards for people who have developed resistance to the effects of narcotics. That is the real definition of addiction, or habituation technically, that the former dose no longer works and progressively higher doses are required. A dose that can kill a horse may not be enough for someone who has been taking narcotics for years.

Perhaps patients' expectations play a role. The narcotics may control the condition somewhat, but no patient with a chronic pain syndrome should live with the expectation of ever being entirely pain free. This is a difficult message for physicians to deliver to a patient who believes they cannot live with their condition.

When patients get insufficient medication, they will often look for another doctor, and so they become doctor-shopping drug-seekers. We see this most clearly with sickle cell patients who quickly learn how to get pain relief. A few even learn how easy it is to abuse the system, since there is no objective way of verifying the patient's level of pain.

When I was in medical school, Dr. Ronald Melzack, one of the foremost pain theorists to ever walk the earth, was encouraging the use of narcotics for chronic non-cancer pain. I'm not sure he was aware of the depths to which a drug addict will go to get their drug of choice, even in the context of genuine pain. I was uncomfortable then, and the passing of time may be proving me right.

It is difficult to find the full-text of a medical journal online, but a quick search yielded a review that outlines the state of the art for non-cancer pain. I would draw the reader's attention to reference number 34 (which is actually mis-attributed in the text) and the following excerpt:

Unfortunately, as with the non-narcotic pharmacologic treatments, a review of the literature gives no evidence of scientifically designed, controlled, double blind studies with follow-up demonstrating narcotic medication as being consistently reliable in providing relief of chronic SCI pain. Generally, both proponents and opponents of long term opioid use in central neuropathic pain have submitted anecdotal data in support of their respective viewpoints.

Although this article is nearly ten years old, my understanding is that the data are still lacking.

There is no denying that a minority of individuals consciously and intentionally go to doctors for the express purpose of obtaining drugs to sell on the underground market. There is also no doubt that some physicians document their patient visits poorly. But we have created a nation of drug-seeking junkies since patients don't trust doctors and doctors no longer trust patients, especially when it comes to the prescribing of pain medications. Now the very act of asking for a pain medication is enough to raise suspicions.

How does management weigh in? Well, first, we are concerned about patient satisfaction. A few month ago, my CEO marched into my office concerned about a patient complaint. The patient had stated the physician was uncaring, refused a prescription and did not listen. I refused to discipline the physician, since the request was for narctoics. I recently had a conversation with another medical director who felt his young doctors were being unnecessarily prickly about prescribing for pain. I don't have enough information to comment, but I suggest a lot of caution.

No narcotics can be prescribed in the US without a DEA number in the physician's name. No employer should ever question the appropriateness of a refusal to prescribe under a DEA number. Moreover employers should take precautions to ensure that the doctors' DEA numbers are not used indiscriminately by other staff within the company.

Part of my job is protecting my physicians and the organization from litigation and/or investigation. We have instituted policies that will make it very difficult for patients to get prescriptions for narcotic pain relievers, and virtually impossible for a new patient whose doctor doesn't contact one of our physicians first, to validate the situation.

It's really too bad, because this leaves a lot of people in pain. The truth is the drugs don't help patients as much as they think. The truth is the interactions between patients and physicians around pain have deteriorated to the point that some doctors may just refuse to prescribe. The truth is the DEA is sending good doctors to jail along with the bad (108 prosecutions in the past 4 years, according to the AP.)

I do not see a way out of this conundrum.