You can’t turn on the news today without hearing something about “The Opioid Crisis”. And here I am signing pain medication agreement contracts DAILY.
I’m one of the newest physicians in my group and the community that I’m working in recently had 3-4 doctors leave. This means that I am seeing a TON of new patients every day and a lot of these patients are requesting a “pain management contract”. How is it that this terminology is so ubiquitous in our culture? Why are there sooooo many patients on chronic opioid therapy.
I’m frustrated that I’m signing these contracts to continue these medications. I’m frustrated that I’m frustrated. I’m a physician. I’m supposed to help people. If my patient is in pain then why would I withhold something that provides them with pain control? I suppose that was the thought process of the physicians that started these patients on opioid pain medications 10-20-30 years ago. But now, it’s fallen to me to determine if this patient sitting in front of me is appropriate for this type of medication. Or if something else might be better treatment for them. So, I spend time – and a lot of it – in new patient/chronic pain appointments.
Here’s how the encounter goes:
Patient requests “pain management”. I agree to discuss this.
They tell me they’ve been on oxycodone 15 mg every 4 hours for the past 20 years. I say, “Gosh, that’s a lot of pain medicine” and calculate the morphine equavalent to 135 using this calculator http://www.agencymeddirectors.wa.gov/calculator/dosecalculator.htm.
I then discuss the recommendations that opioids not be used for chronic pain at all and if they are that the MED be below 50 to avoid bad effects – like DEATH. The patient launches into a long explanation of why it’s impossible for them to take less than what they are on right now.
I try to take a good history. Figure out where the pain is (all over), what work up has been done (everything that could be, but of course they can’t provide records from prior physicians), and what treatments have been tried in the past (EVERYTHING, but nothing else worked and they can’t possibly be expected to go through all that again. PT just made everything hurt more).
I discuss the way that mental health and physical health are intertwined and especially how chronic pain and depression are related. Does this patient have any mental health issues? Would they be willing to attend counseling or a chronic pain group to help them deal with this? (No, they’ve done that before and it didn’t help. They’ll be fine if I just give them the oxy).
I ask about drugs and alcohol use (they act indignant. Of course, they would never use drugs or drink any alcohol).
I check the state prescription monitoring program and see if what they’ve told me jives with what is on the report. Often not. There’s always some reason – I moved, my doctor left, they cut me off for no reason, my doctor doesn’t understand my pain.
Would they provide me with a urine sample for a drug screen? (well, they can’t pee right now and their other doctor never made them do that).
At this point I have a good idea of whether I think I am willing to enter into an agreement with this person. I will hardly ever prescribe opiates on a first meeting. Maybe if everything is in order – meaning I have records from prior physician, I agree with the indication for opiates, the PMP shows no aberrency and the patient provides me with a clean drug screen — Maybe. Frankly, nearly all the contracts I have continued have been transfers from my partners that retired. Sometimes I’ll tell patients I need more information and they’ll have to come back with records.
Often, I will tell people that I don’t feel there is an indication for continuing opioid medications and that I am not willing to enter into a contract with them. Most will argue and tell me again how much pain they are in. They will threaten to go buy it off the street. They will threaten to kill themselves. They will threaten to report me to the medical board for malpractice. I ask them if they would like to discuss other medications for chronic pain (nothing works). I ask if they’d like to talk to someone about their mental health (no way – and this usually makes them really angry). I ask them if there is any other aspect of their health they wish to discuss.
If not, I exit the room and will probably never see them again. They will try the next doctor. This thorough evaluation has cost me about 30 minutes of my time or more. Is it wasted time? I don’t know. It feels like it. These encounters suck the life out of me. Like I’ve been in the room with a dementor from Azkaban for 30 minutes! I suppose one could argue that it does provide education for the patient and each encounter they have like this is reinforcing the agenda that we are trying to achieve. It sure doesn’t do much for my agenda to fight physician burn out though.
I hate that I roll my eyes every time someone comes in for chronic pain. Because, you know what? People have legit pain that needs evaluated! I try to approach every encounter in an objective way, but it’s hard. How do I help people use these medications judiciously and with a functional goal in mind? How do I help people who have been on them for 20 years wean down? Or should I? Should I leave well enough alone and allow them to continue as long as there are no significant adverse effects, they follow the contract and they feel they are getting benefit? Am I vilifying a potentially helpful treatment option?
And it really stinks that the new generation of physicians are stuck dealing with this crisis that we did not create.
I’ve started keeping count of everyone that I help wean off opioids, decline to continue or decline to start. It makes me feel a tiny bit better to look at it as it gets longer.
So, teaching people how to manage chronic pain without opioids — that’s my opioid crisis.