It is one of the biggest struggles and least favorite areas of being a doctor, yet it is something I see far too much: patients taking short-acting narcotic pain medications for chronic pain. There is a degree to which it a good thing, allowing people to get regular prescriptions of smaller amounts of pain medication to use for increases from their background pain; but far too many of them call for their prescriptions on the month, often asking for a little bit more this month because of increased pain. Many doctors see these people as "drug-seekers" - a description with a very bad connotation, implying that the medication is central, not the pain. While I know there are drug-seekers out there, many of whom feign pain so they can get prescriptions and then make money selling it, there are also a lot of people with bad pain who want to escape. In fact, I try to make that number 100%, as I want nobody lying to me to get medications they don't need or use. Those phone calls every month for narcotics, often trying to get it a little early, get a stronger dose, or get more in each prescription, I think are people who really hurt and really think they need the medication.
But short-acting medications are a deal with the devil when used regularly for chronic pain. They create more problems and much, much bigger problems than they treat. So in response to this, I am starting to send the following letter to my patients who are using medications like this on a regular basis:
I am sending this letter to patients who are using narcotic pain medications on a regular basis for chronic pain. I am doing so, not as an accusation or a sermon, but to educate you as to the reasons use of medications in this setting is not only risky, it almost always will cause problems down the road when used for a chronic problem. This also does not imply that I will not give prescriptions for these medications when you need them. I will give pain medication for appropriate pain, but I will also do everything possible to minimize the use of short-acting pain medications. What follows is an explanation as to why I think this is so important.
Chronic pain is pain that lasts for a long time - more than a month. While it is OK to use short-acting pain medications (like hydrocodone or oxycodone) for short-lived pain (like that from an injury), it is not good use them regularly in long-term pain. • It may work for a short while, but the body develops a tolerance, requiring the dose to go up to get the same effect. • Going up on the dose will only work for a while, and then an even higher dose is required. • Eventually the person with chronic pain will require very high doses of narcotic to get even a modest effect. • Being at high doses like this comes at a cost: withdrawal. A person on high-dose narcotics (especially short-acting ones) will always cause withdrawal when the medication is stopped. Withdrawal from narcotics is far worse than the pain for which the medications were given. • To avoid withdrawal, the person on short-acting narcotics must continue taking the medication, creating a dependency on the drug that is hard to escape, while at the same time offering little pain relief. It’s a horrible trap. • Additionally, patients who take large amounts of narcotics are often labelled as a “drug seeker” by any new doctor they see or hospital they visit. If this happens, it is much less likely the person will be taken seriously by the medical professionals. • Finally, the doctor prescribing pain medications in large quantities puts his/her career at risk by doing so. Careless prescription writing invites abuse by patients - something that can cause a doctor’s license to practice medicine to be taken away, and may even result in criminal charges. It is good to be concerned about a person’s pain, prescribing short-acting pain medication for chronic pain only promises to add a new problem to the picture: dependency and addiction. The life of a person with chronic pain is bad enough without the dependency on narcotics, so the use of these medications except on an “as needed” basis for break-through pain is to be avoided.
Can anything be done for the person with chronic pain? Yes, but the expectation should not be that the pain will be eliminated; it will only be reduced. Here are ways to deal with chronic pain without the regular use of short-acting narcotics: • Some antidepressants and seizure medications can reduce the overall need for pain medication. • Treating the underlying problem (back surgery, for example) can reduce pain. • Injections of cortisone or local anesthetics, as well as procedures done to block pain by pain specialists can help in certain circumstances. • Long-acting narcotics (like Oxycontin, MS-Contin, or Duragesic/Fentanyl patches) can be used to lower the overall pain level, allowing short-acting medications to be only used as needed for breakthrough pain. This is much less likely to cause dependency, relieves pain better than short-acting medications alone, and uses less medication in the process. These do, however, put the person at risk for withdrawal symptoms if stopped suddenly.
If none of these work? The sad answer to that is that the person will have to live with the pain. Adding short-acting medication may offer short-term relief from the pain, but the long-term problems it inflicts are far worse than any benefit they have.
I hope this helps you. I always want to have my patients feel the least amount of pain possible, but there are some things that may seem like they help in the short-term, but really cause problems much larger than the original pain. I will work with you to find ways to minimize the need for these medications. You should do everything you can to use them sparingly.
Again, I am happy to take care of you, and this letter is an attempt to give you the best care I can.
Robert Lamberts, MD
I don't want my patients to hurt, but I also don't want to be party to hurting them more - even with the best of intent. I hope this letter helps them see. I hate to tell some people that they just have to feel pain, but unfortunately that is usually a better option than these medications.