Over the years I’ve been in practice, I’ve learned a great deal, but much of it cannot be used “in general” or “across the board”. As I sometimes tell my physician colleagues in other specialties, if you’ve seen one chronic pain patient, well, then, you’ve seen one chronic pain patient. A patient’s pain is like his or her fingerprint. It’s unique. Always unique. As are the life circumstances surrounding the chronic pain. I never forget that for many of you, your chronic pain has forced enormous changes upon you and those close to you, and rarely are these changes for the better. Every medical specialty has its own set of occupational hazards, and for those of us specializing in treating pain, becoming overwhelmed by human misery and burning out is a biggie. So too, for a patient, every treatment, regardless of which subtype of physician renders it, has its hazards. In pain management, I think we’ve really gotten quite good at minimizing procedure risks. Every doctor who is in a hands-on, technique-driven field of medicine or surgery dreads harming a patient by way of his/her own hands. Each one of us in anesthesia and pain management has a case or two that we try to move beyond, a case where despite having nothing but the best intentions, we’ve managed to make a patient’s condition even worse. But again, in pain management, with the help of our great staff of nurses and techs, we’ve made the fluoroscopy suite a pretty safe place.
Yet most all of you know that, however technically advanced, no pain management procedure or surgery can make a patient good as new. Remember being taught about the concept of “entropy”, meaning that the number one rule of our universe is that things always always always move from order to disorder. Things go from fixed to broken. Things go from new to old. From healthy to sickly. From alive to dead. And it just never never never will go the other way. Well, ok, it DID go the other way just once, but that was 2000 and some odd years ago, and that was a very special case indeed.
If the procedures we render have gotten safer and safer, I don’t believe the same can be said of the medicines we prescribe. Some, if not respected by doctor and patient alike, can and do irreparably damage the kidneys. Others, the liver, and yet others, the stomach. But it is one particular category of medications that we carry in our armamentarium that rarely causes ANY organ damage, and yet can utterly destroy the very lives we are trying to save. Lately, these drugs have been portrayed as so dangerous that many physicians refuse to prescribe them or even have them in their offices. And yet, we cannot fool ourselves. These drugs are absolutely vital to controlling pain. To refuse to prescribe them is to say to the patient “Yes, I think you really need these drugs, but I’m not comfortable giving them to you”. Really? I would hope that deep inside, every doctor accepts that his or her “comfort” is hardly the issue. When a patient is in crisis, what in God’s name would my “comfort” have to do with anything? I’d tell any young student who wants to become a doctor that if you think you are signing up for respect, power, and some decent money, and a worthwhile life, indeed you are, but one thing you aren’t signing up for is comfort. Along with the good stuff, you are signing up for discomfort, fear, anxiety, dread, fatigue, sadness, and regret. “Comfort”? Not a good word choice.
I often tell my patients that the one really good thing about being a doctor is that 99% of the time, I get to be absolutely honest with my patients, and to me that feels really good. Plus, if I’m honest, I don’t have to remember everything I’ve said (Mark Twain wrote that I think). So, allow me to rewrite that above-mentioned “but I’m not comfortable giving them to you” bit so that at the very least, its honest. So, here is what the past few years of the “opioid crisis” have done to the way most doctors outside of pain medicine think. And it would go something like this:
“Yes, I think you really need opioids, but I am afraid to give them to you, because………….
- I’m afraid that you will take too many of them and hurt yourself
- I’m afraid that you will take too many of them and show up in the ER where my colleagues will question my judgment/skill/competency
- I’m afraid that the DEA and the state’s attorney are cracking down on over-prescribing doctors and I’m afraid I’ll be shamed in the papers/online or I’ll lose my license or my practice or my money or my family when I go to jail
- I’m afraid that you are not being honest with me and are pretending your pain is worse than it is so that you can get narcotics to sell/abuse/support your addiction and I’ll get sued or someone else will die
- I’m afraid I’m missing a diagnosis and perhaps this is all anxiety and depression and you’ll kill yourself with them or maybe it’s a cancer I’m not uncovering and so I’ll have your death on my hands and on my soul
- I’m afraid you are one of those fake patients who are really police officers or agents and you are coming here to see if you can trick me into prescribing so you can take my license
- I’m afraid that I am putting you on the pathway to heroin addiction and homelessness and an early death and it will all be because of me and what I did because that’s what the addicts say happened to them on those TV shows
- I’m afraid that I am missing a truly better more effective treatment that you will eventually find and look back on me and all the years you wasted because I didn’t find the truly effective treatment for you
- I’m afraid that this is one of those life-changing moments for you where you are supposed to tell me you don’t want that and then you’ll go to the gym and then you’ll eat right and look and feel great and I’ll be the guy who almost derailed all of that for you
And here comes the mother of them all…….
- I’m afraid that I am failing as an allopathic physician and, in my failure, betraying all those who taught me and trained me because after all, quacks cover up symptoms while doctors actually cure patients
Remember how I said that these are the thoughts that go through the minds of doctors outside of pain management? That’s not entirely true, because over the past few years of unrelenting opioid crisis coverage, these same bad thoughts have started to go through my mind.
So now you know my heart. I daresay I’m not alone here either. I/we need your help. If you are willing to help, or feel that I/we deserve your help, please start by simply re-reading the opioid agreement you signed when you received a prescription from you pain specialist. In my next piece, I’ll talk to you more about that agreement, and how in the end it is really the only thing that stands between you and I and future massive restrictions on pain medicine outside of the hospital.