When I first started working in pain management 32 years ago, my partner and mentor, Kit Mays, MD, used to say that our practice was limited to treating what nobody else wanted.

Chronic pain patients often were judged as having mostly psychosomatic problems and healthcare professionals were not always receptive to their complaints. In those early years, pain specialists were far lower than proctologists on the medical prestige scale and medical students shunned pain fellowship spots.

But times have changed. Even non-medical people now are familiar with endorphins, and at any given social encounter someone will argue the benefits of diverse nerve blocks as if he were an expert. Regarding medical education, in 2011 the pain fellowship program at Jackson Memorial Hospital in Miami received hundreds of applications for just three openings.

As pain management has gone mainstream, so has the widespread use of opiates in daily medical practice. In just a few years the pendulum swung from few opiates being prescribed for fear of addiction and respiratory depression, to the erroneous mantra,  “there’s no upper limit to the dose of opiates, as long as the patient has pain.” The liberalization of the use of strong painkillers, which started as a great cause and a true desire to alleviate human suffering, has now degenerated into an epidemic of opiate misuse and abuse – the proliferation of hundreds of “pill mills” around the country, and a four-fold increase in the number of deaths from these drugs in just ten years. Hydrocodone has now become the number one drug of abuse in the country, mostly diverted from legitimate prescriptions.

A justifiable public outcry has compelled politicians and law enforcement officials to respond to the threat that this deluge of narcotics poses to the community. Primary care physicians were quick to notice the winds of change and many, fearful of the additional pressure to their practices, simply stopped prescribing controlled drugs altogether. Which brings me to my point.

Our clinic once received mostly referrals of difficult-to-manage pain and oftentimes problem opiate users, but lately we have seen a fair number of referrals that were, until then, adequately managed by their clinicians with even modest amounts of opiates. From older folks with osteoarthritis to young girls with intermittently severe menstrual cramps, these are patients who, sometimes for years, have benefited from the judicious use of painkillers, now told by the physician who knows them best that they need to be referred to another specialist “for pain management.”

Don’t get us wrong, we do appreciate the business and we are more than happy to accommodate our colleagues when difficult cases demand our expertise. It is unsettling, however, to see clinicians who know their patients well, put in the position of limiting the scope of their practice and reluctant to use some of the most effective analgesic drugs in their arsenal. Furthermore, no one can be insensitive to the onus imposed on the patient of yet another specialist, another co-pay, and another workday missed.

Good physicians should keep their opiate prescribing skills and hold their ground. True, eliminating opiates from your practice may avoid some regulatory headaches and the occasional drug seeker, but it will also rob you from the satisfaction and joy that physicians can experience with a job well done.

When asked, I suggest that clinicians follow some simple rules to ease opiate prescribing:

• Modest doses of opiates are sufficient in greater than 90 percent of patients who may benefit from them. When you step out of your comfort zone, refer.
• Try to use the lowest dose available in a pill or capsule; drug seekers will look elsewhere for easier, more profitable ways.
• Remember that older folks are less likely to develop dependency, but they are more likely to have their medications stolen by family members.
• A well-placed sentence during your encounter regarding use of the medication may suffice for record keeping.
• It is easiest to incorporate a controlled substance agreement when added to a new patient package. Ours is comprised of 10 simple rules (just ask and we’ll send them to you).

Moacir Schnapp, MD, whose background is in neurology has been in partnership with Kit S. Mays, MD, over 30 years. They practice interventional pain management at the Mays and Schnapp Pain Clinic and Rehabilitation Center, treating Mid-South patients who suffer from chronic pain with a multi-disciplinary approach.

Tags:

Related:

Bookmark:

Digg

Facebook

Technorati

Newsvine

Google