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IN PRACTICE

Why doctors are uncomfortable prescribing painkillers

(Dan Page for The Boston Globe)
By Dr. Suzanne Koven
Globe Correspondent / October 24, 2011

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The woman gripped the arms of the chair, anxious about her root canal. To put the patient at ease, the endodontist chatted.

For the next two hours, as he poked and prodded her numbed jaw, he distracted the woman with tales about his childhood, marriage, and kids. The woman felt grateful to the charming doctor who’d provided care both skilled and compassionate. She left the endodontist’s office with a warm handshake and a Percocet prescription.

Three days later, she called the office for a refill. She was still in a lot of pain, she explained. “Impossible!,’’ the endodontist pronounced. “You shouldn’t be having that much pain at this point.’’ His chilliness surprised the patient. The nice rapport they’d shared during the root canal seemed to have vanished.

I was that woman. When this happened a few years ago, I experienced, in quick succession, three emotions. The first was anger. How dare he tell me that I “shouldn’t’’ be in pain? The second was shame at the memory of the many times I, too, had rolled my eyes privately when a patient’s need for narcotics exceeded my expectations. The third was bewilderment. When did we clinicians become so uncomfortable with alleviating pain - that most basic of the healer’s duties?

Part of health professionals’ reflexive wariness about patients’ requests for narcotic pain medication has to do with the drastic increase in recent years in prescription drug abuse. In 2010, the White House released a study showing a 400 percent increase in such abuse between 1998 and 2008, when there were 300,000 visits to emergency rooms in the United States for misuse of prescription drugs.

In 2007, the most recent year for which records are available, the Massachusetts Department of Public Health identified nearly 3,000 people in the Commonwealth who’d presented prescriptions for narcotics from multiple prescribers to multiple pharmacies - many of them, presumably, intending to sell the drugs.

High profile deaths, such as Michael Jackson’s, from prescription drug overdoses, have brought attention to a national crisis caused by a complex mixture of factors. Increased demand by patients for pain relief and doctors’ increased willingness to meet that demand - encourgaged partly by drug company marketing - has placed larger quantities of highly addictive drugs such as OxyContin into the illicit marketplace. Decreased funding for tracking and treating abuse has also contributed to the epidemic.

Still, doctors’ discomfort with treating pain long predates this most recent crisis. In her excellent 2010 book, “The Pain Chronicles,’’ journalist Melanie Thernstrom recounts the various ways in which, throughout history, clinicians have recoiled from dealing with patients’ pain. One of the most ignominious was doctors’ refusal to believe, until not so many decades ago, that people of color and children were fully capable of experiencing pain.

Thernstrom argues that pain doesn’t fit neatly into the traditional ways of thinking about diagnosis and treatment with which doctors are most familiar. Pain is highly subjective and heavily influenced by a person’s psychological state, so much so that it can look “voluntary’’ at times. Thernstrom herself has suffered from chronic neck pain for years, from a spine condition demonstrable on MRI. She started having this pain on the very day she entered an unhappy romantic relationship.

Pain, unlike, say, a broken leg or strep throat, or even a psychotic episode, is hard for a physician to characterize. Harvard professor Elaine Scarry, author of “The Body in Pain,’’ observes: “To have great pain is to have certainty; to hear that another person has pain is to have doubt.’’ Doctors don’t like having doubt.

We also don’t like feeling helpless, which is how patients with intractable pain can make us feel. Sometimes we can’t get their pain under control because we haven’t found the correct diagnosis or effective treatments. And sometimes the patient’s pain is entwined with so much other stress - family and financial problems, for example - that nothing seems to help. As a colleague of mine put it, these are the patients whose very lives seem to hurt.

That’s not the case with a patient I’m treating now. He’s given me permission to share his story here, anonymously. He’s a healthy young man who loves his work and is happily married. An injury he sustained a few months ago has been life altering. It’s caused nagging pain in his back, which persists despite physical therapy, a steroid injection, and consultation with a pain specialist. He’s made some progress, but he still needs to take Vicodin every day for relief.

The up side of the Vicodin is that it helps him feel well enough to keep working and to function at home. The down side is that it causes constipation, dry mouth, and a feeling of being out of sorts. People on narcotic medication are often mildly depressed, even on the verge of tears at times. Other side effects can include difficulty urinating, sleepiness, and nausea. Though these drugs are used recreationally by some, for most patients in pain they aren’t much fun.

Another potential side effect of narcotic medication is subtle and not often enough talked about: It can affect a patient’s relationship with his or her doctors.

On my patient’s recent visit we spoke frankly about this. He’d had a setback, and required more Vicodin than usual. He happened to call for a refill while I was out of the office, and one of my colleagues, rightly, required that he come in and be examined before receiving another prescription.

I told the patient that I imagined this must have felt kind of humiliating, as did being required to request Vicodin anew each month. I also shared with him my concern that he had become addicted to the drug. We acknowledged that his ongoing need for Vicodin had injected a certain degree of tension into our encounters.

Frequently, doctors write up formal “narcotics contracts’’ with such patients, stipulating how much pain medication they may receive, how often, and from whom.

I’ve found such contracts helpful in the past, but have elected not to use one with this patient. He and his wife are expecting their first child, and he wants to be as healthy and sharp as possible. He’s very motivated to taper off the Vicodin. We’ll keep in close touch as he does, still looking for alternative ways to manage his pain.

And while we try to get a better handle on his use of painkillers, I’ll keep trying to get a better handle on why it bothers me so much.

Dr. Suzanne Koven is a primary care internist at Massachusetts General Hospital. She writes a monthly column about the uncertainties, dilemmas, and stories that patients and doctors share in practice. Read her blog on Boston.com/health. She can be reached at inpractice@gmail.com.

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