Pain control: Let’s rethink our prescribing habits

When it comes to prescribing narcotics to control pain, I think I owe someone an apology. I can honestly say I didn’t mean to cause a problem. Further, I’d argue that I was practicing what was considered at the time the normal boring standard of care. But if you listen to the news recently, or even the U.S. Surgeon General (I assume everyone received his August 2016 letter), you’d think I was Josef Mengele.

I attended the University of Michigan Medical School between 2003 and 2007, and one of the required classes during the first years was a multidisciplinary class. It was a great break from time spent memorizing the Krebs cycle and allowed us to think that we were practicing medicine. Once a week, we sat down in a small group setting and talked about various clinical situations.

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It was in that class I was “taught” that narcotics were not addictive and that it was my responsibility as a physician to control pain. Hence, as I entered residency, I was primed and willing to write narcotics. Most of the attendings in my residency at the University of Iowa seemed to agree. But one did not.

Richard D. Williams, MD, was right, as it turns out. Dr. Williams, as many of you know, specialized in prostate cancer and performed thousands of open radical retropubic prostatectomies. I only had the privilege of scrubbing with him once during a prostate as he stopped operating when I was still a junior resident at the University of Iowa, but I remember a wise and confident surgeon constantly pimping one of the senior residents during the case. The only thing I did on that case was cut suture, and I wasn’t sure if he even realized I was there until the end of the case when he turned to me and reminded me to find him the following morning to take him to round on “our” patient.

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Early the next morning I walked my chairman to see “our” patient. I had been on call that night and had poked my head in a few times to check on this particular man, as I had no intention of messing up my first real encounter with Dr. Williams, whom all the residents simply referred to as “Boss.” The patient had abdominal pain near the incision overnight so I had increased his pain medicine from tramadol, which was on Dr. Williams’ pathway to acetaminophen/oxycodone (Percocet). Of all the decisions I made overnight, that one seemed the most straightforward.

Boy was I wrong. When Dr. Williams learned that I gave one of his patients Percocet, he spent the next 10 minutes lecturing me on the dangers of narcotics and how most pain can be controlled with non-narcotic methods. I left that interaction puzzled as I remembered well the lessons I was taught in medical school and was unsure how to proceed. I remember talking to the other residents and learning about Dr. Williams’ preference, but given that this was one of my few surgical interactions with the Boss, my own prescribing pattern when I graduated residency and started work in the real world were markedly different.

Next: "Given the pain pill epidemic, my assumptions need to be reviewed"

Let’s be honest here, pain hurts. I work near a large army base and soldiers who have taken bullets tell me that kidney stone pain is worse. Moms have told me that stones are worse than childbirth. If someone is passing a stone, Percocet seems like the least I can do. But clearly given the prescription pain pill epidemic that has swept the nation, my assumptions need to be reviewed.

But first, how did we get here?

The best article I found on the history of the narcotic epidemic is by Celine Gounder in the New Yorker. In summary, the academic groundwork for the paradigm shift from prescribing narcotics only to control surgery-related pain or at end of life (which are the historical indications for narcotics) to its broad use was a 100-word letter-to-the-editor published in the New England Journal of Medicine in 1980. This was followed by an article published in Pain in 1986 that concluded narcotic pain medicine “can be safely and effectively prescribed to selected patients with relatively little risk of producing the maladaptive behaviors which define opioid abuse.”

With that minimal data in hand, a toxic mix of pharmaceutical company advertising and the government messages (thank you, Joint Commission) encouraging and prioritizing pain control (the visual analogue pain scale was mandated in 2001) led to the environment that I grew up in. Once we, as a medical community, started more broadly prescribing pain medicines, it’s a tough habit both physicians and patients to break.

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So, what do we do? For myself, I have adopted a two-step process that I hope limits my contribution to the problem. First, I think it’s important to acknowledge that pain hurts and that I have a responsibility to treat it. With that in mind, I still liberally and willingly write narcotics for the historical indications of post-surgical and end-of-life pain control, and I have also added the treatment of stone pain to this list. On the other hand, when the acute pain is over, I very bluntly tell patients that I do not prescribe narcotics but am willing to send them to a pain specialist if non-narcotics options are not working.

Second, Colorado has a wonderful and easily accessible database that allows me to see if a patient is receiving prescriptions for pain pills from more than one physician. The Prescription Drug Monitoring Program is a free, quick-to-access online program that I can check in my office and quickly see if a patient is doctor shopping.

Lastly, the extent of the prescription pain medicine epidemic is so broad that every patient has heard of it and understands that the government is taking steps to minimize it. With that in mind, patients understand when I say that there are limits on what I can prescribe and they seem willing to accept that as long as I offer to send them to a pain specialist. I realize that may be kicking the can down the road, but the long-term management that is required for patients on chronic opioids is beyond the skill set of this small-town plumber. This strategy hasn’t always worked, and I’ll concede that a few patients known to our office who try to game the system, but I’m confident that it’s better than what I was doing until recently.

Medicine changes. If you are the person to whom I owe an apology to for my previous poor prescription writing, I am sorry. I will continue to endeavor to practice standard, boring, state-of-the-art medicine, but I am a little more aware today how fluid that definition is.

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