OPIOID PRESCRIBING: A GENERATIONAL PERSPECTIVE

Faculty Physician

Fresh out of residency in 2004, trained in the era of “pain is the fifth vital sign” and the upswell of OxyContin prescribing that began in the mid to late 90s, I felt overwhelmed by the number of my patients suffering from chronic pain and unprepared to help them. A woman with bipolar disorder had compartment syndrome in her right arm after a suicidal ingestion that left her unconscious in her car for 18 hours. The muscle atrophy and scars from fasciotomy were impressive, resulting in a combination of severe neuropathy and hyperalgesia that were impossible to heal, and it was with consultation that I prescribed her fentanyl patches and later methadone for pain. The guidelines at the time purported that patients receiving opioids for pain relief did not become addicted and that doses should be titrated to pain relief without a ceiling. Medicine has no pain-relieving options more immediately effective than opioids, and I remember the discomfort of first realizing I have the power to dispense or withhold them based on my own judgment of someone else’s suffering, and first experiencing the anger and fear this can generate in patients. It is much clearer today than it was then, that a policy of unlimited dose escalation for chronic non-cancer pain is a recipe for dependence, addiction, overdose, potential diversion, and little to no benefit. The drawing of rigid lines, however, can disregard the situations where these powerful medications can provide significant improvements in function and quality of life. I see doctors coming out of training today, immersed in the crisis of opioid addiction, and fearful of offering even very small prescriptions of opioids or of taking on the challenge of connecting with patients who have been dependent on them for decades. The laws and regulations that now limit my prescribing are based on better science, and I try not to resent them as I fill out prior authorization paperwork to allow my patients access to pain medication when I believe they do need it. We are all constantly looking for that balance between compassion and caution, between guidelines and individualized medicine.

Resident Physician

She has a deep vein thrombosis (DVT). It is the first textbook DVT I have seen in my short career, but she won’t go to the hospital. She is here today for her 50 MME of codeine and morphine. I have never met her before. She is angry at me because I don’t want to prescribe her monthly prescription unless she goes to the hospital; I worry her narcotics are concealing her life-threatening pain. I feel helpless; I feel like a drug dealer. I do not feel that I am helping her and I don’t know how to help her. The surge of frustration rises; I want to quit. I alternate rapidly between disgust and pity and confusion. The laws are mounting and the insurance coverage is tightening against my choices, but I have not started ANY of my patients on regular controlled substances. I am drowning in evidence against chronic opiates for these diagnoses but cannot follow any of the recommendations without losing these patients or putting them through withdrawal and suffering. I have walked into a trap of addiction and these patients will desperately and persistently strategize ways to maintain access to my prescribing habits. When I start my clinic day, I look up all new patients on the state controlled substance database. I scan for other acute pain complaints to make sure I am prepared for the demands of my opioid-seeking patients. I avoid starting new patients on these high-risk medications unless there is a very clear clinical need. I seek alternative therapies, though most patients cannot afford acupuncture, talk therapy, or topical analgesics. I set appropriate expectations for pain management, but this is not helpful for the patients I inherited. What I am lacking is the ability to safely treat opioid dependence. I don’t know how to help them, so I sustain them.

Two stories, two generations, one emotion: frustration. As resident education moves forward, family medicine must be a part of the solution to this epidemic. Resident physicians are an untapped resource in the opioid epidemic. They are desperate to get their patients off these substances and are driven to set boundaries with the patients they inherit, but they need the training. More family medicine residency programs are offering training in pain management and care of those addicted to opioids. More family physicians trained in buprenorphine prescribing, better access to behavioral health specialists, and an education of our population about reasonable pain management are needed. There are encouraging efforts by family physicians to promote legislation supporting these goals. In the meantime, we need to listen to our shared experiences and learn from them.