I was reading this article this week, and I found myself with so many thoughts about the various facets of the pain/addiction spectrum represented here that I am actually intending to write several posts to explain them all. For this week, though, I want to talk about one of the reasons why this blogger’s friend’s wife was treated so circumspectly by her pain management physician. It’s true that physicians often fear punishment from the DEA, which may include losing their license. There are other reasons doctor are afraid to deal with pain patients, though.
A few months ago, I went to a pain management conference in Atlanta, where I learned a lot about the whole pain management industry. While individual stories like this are true — and terrible — they also can be, and often are, exploited as a tool by pharmaceutical companies hoping to scare doctors into over- instead of under-prescribing. For decades now, that’s exactly what has happened. Many of the patient advocate groups that support constant, aggressive pain management, and argue for physicians to be released from liability in prescribing large doses of pain medications, also receive large grants from the pharmaceutical industry that help fund their efforts.
Advocacy groups backed by companies with a financial stake in the matter have pushed the concept of pain as a “vital sign” that should be assessed and treated on every single patient, even those who did not originally complain of pain. This is a framework that was adopted by most state medical boards in the mid-1990s. In retrospect, it is now considered one of the most blatant examples of biased influence of the medical profession. Ever since this framework came to be widely adopted, pain medications have been overprescribed with impunity by physicians, despite there being no evidence that long-term narcotics are effective for chronic non-cancer pain, and despite overwhelming evidence of the risk of developing addiction.
Now, though, we may be beginning to see a legislative backlash that seeks to err on the side of under-prescribing. We often discuss on this blog where to draw the line between over- and under-prescription, and of course the answer is always that no answer is clear-cut. It certainly seems odd that the primary physician of the woman in the article above wouldn’t believe or care that she had been to the ER; but take into account that many opiate-addicted patients are “drug seekers” willing to exploit physicians, and it becomes more understandable (though not excusable. Part of the physician-patient relationship is an understanding of which patients have earned the leeway that comes from trust). Why are physicians suspicious of patients asking for opioids? Possibly because of the public stigma attached to addiction, or the fact that there are no good safeguards in place to prevent the prescription system from being exploited, or that the DEA has been cracking down on what it views as overprescription. The DEA’s view may be overly strict, as a reaction against the overly permissive opiate-prescribing policies that have held sway over the last twenty years. “Pain Contracts” may be overly restrictive in some cases and desperately necessary in others.
Whatever the answer, we can be sure that, in both the addiction and pain-management communities,both sides are going to exploit the (often tragic) stories of patients who illustrate their points. Nobody wants anyone to suffer unnecessarily; the problem always seems to stem from who has the power to decide what is necessary. Regular readers should know by now that I think it should be a decision between patient and physicians, but it will probably never be possible for that to exist outside of some kind of legislative system. We can only hope that we will eventually be able to strike the proper balance.