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Pain Medications


Our Broken System - #3: Dropping the Baton

My patient was angry, confused, and frustrated.

He had transferred his care to me because I take care of his kids and he badly needed help with a terrible pain in his leg that wasn't getting any better.  He went to another doctor - an orthopedist - who predictably focused on the joint as being the cause.  After x-rays and MRI scans of the joint, my patient was told that there was "nothing wrong."  The pain continued to get worse, and he had just now broken out in a rash.  His calls to the specialist were met with suspicion, and flat out rejection.  Now he didn't know where else to turn.

When he finally came to me his pain was excruciating.  He sat across the room, writhing as he tried to find some position that would not be as painful..  His skin was now very sensitive to touch and the rash was very strange in appearance.  His joint exam was entirely normal.  This was clearly not a joint problem; it was a neurological problem.  I knew him from visits with his kids, and never felt he was one to exaggerate or invent symptoms, so I trusted what he was telling me.  Besides, there was that strange rash.  Nothing was working for the pain, and he wasn't taking any narcotic pain medications "because they didn't work."  I asked my partner to come look at the rash, and he agreed with me that this was very likely to be reflex sympathetic dystrophy (RSD), a pain condition caused by trauma to a sympathetic nerve.  It's weird, it doesn't respond to pain medications at all, and it hurts like hell.

He needed pain management to get a nerve block, as no drug I could prescribe would do more than blunt his terrible pain.  But there was a catch: he was a Medicaid patient.  Medicaid patients have two big disadvantages: first, they are very limited in the physicians they can see, as reimbursement is bad; and second,  the reputation of Medicaid patients (partly deserved, partly not) is that they abuse the system and seek drugs.  In our city, the only pain management doctors who treat Medicaid patients are at our local academic facility, Smarty Pants University of Health Science.   This is not good news.  Not only are they difficult to reach, but they tend to view all patients suspiciously. My experience was pretty bad with how my patients get treated there, but I had no choice.

I felt this patient needed to be seen very soon.  To try to reduce the automatic suspicion, I called the pain clinic and spoke directly to the physician.  I explained the history of symptoms, their severity, the ineffectiveness of narcotics, and about the appearance of the rash.  I also reassured him that my patient seemed to have real pain, I don't think he's seeking drugs, and that I suspected RSD.  I was met with an unenthusiastic response and a reluctant assurance that he would try to get my patient in "as soon as possible."  Clearly he didn't believe what I was saying.

A few days ago, my patient came back.  "They don't believe me," he told me, almost in tears.  "They suggested that maybe this was, you know, in my head," he added as he pointed to his head.

"What about the rash?" I asked, incredulous.

"They didn't think much of it.  They told me that they could treat me when you figure out what's going on," he said, getting angry.  I had ordered an MRI scan to assess his lumbar nerve roots to see if maybe this was causing the pain and referred him to a dermatologist to get that angle on things.  His pain was getting no better with the Neurontin I prescribed, and the rash had spread in a pattern that made me question the diagnosis (although not the reality of his pain).

We both sat quietly for a long time, unsure what to say at this.  I sighed.  "I guess I'm going to have to figure it out then," I said, shaking my head.

"And I guess I have to hurt for a while longer," he said.


This story,  in which I've changed significant facts but kept the core, illustrates another broken part of our system: consults. Consulting physician, both academic and private, often result in anger and disappointment on the part of my patients, and very little help in addressing my questions and concerns.

From the patient's perspective, the passing of the medical baton carries the following assumptions:

  1. Care from the specialist will be based on what I've already done
  2. I communicate with the specialist
  3. I trust the specialist to whom I am referring them.
  4. The specialist trusts and respects me.
  5. The specialist communicates with me.

Sadly, none of these assumptions are true in many cases, and all of the assumptions are rarely true.  Why?

  1. Specialists rarely know and often don't care what I've already done on the patient.  Some of this is because they don't have access to the labs I've ordered, the tests I've run, or my thought process up to this time.  We try to send information ahead of time, but somehow that rarely gets in the hands of the person actually seeing the patient, and so many of them don't bother looking.  We've tried to send information through secure messaging (email), but were met with almost universal refusal.  Ironically, the one physician who does engage me electronically works at Smarty Pants U.
  2. Some of the problem is on my part as well.  I don't send a note to the specialist saying why they are being sent.  Yes, they do get an ICD-9 diagnosis, and usually some supporting documents, but they almost never know what specific question I want answered.  Some of this is because I am busy and don't have the time to do extra, and some is because the specialists  are busy and don't like to be bothered with extra.  Regardless, the baton is nearly always poorly passed.
  3. I often can't send patients to the specialists I prefer.  There are some specialists I know and respect, and I try to use them as often as possible.  But often I am sending patients to someone I have never met and know only by the notes they (sometimes) send back.  The story in this post underlines the fact that Medicaid patients are much more likely to get my "less-preferred" specialists.
  4. I am not always trusted.  This is especially bad in the academic setting; they assume that a community doctor is too dull-witted to work at Smarty Pants U, so take everything I do and tell them with skepticism. But this is also true with some community specialists, who think a PCP is to dull-witted to be a specialist.
  5. Specialists are increasingly bad at communicating with me about the patient (and business, I might add) I sent to them.  A significant proportion of my consultants don't send their notes in a timely manner, if at all.  When I do get their note, they are usually filled with useless information, telling me the patient's entire history (which I, of course, already know), exam, habits, shoe size, and whether they have an inny or outy belly-button, all before they get to the part I want: the assessment and plan.  I often have to go through 4-5 pages before I get to useful information.  Additionally, I rarely have access to results from labs and tests done by that specialists.

The failure of the successful transfer often results in what my patient got: frustration and problems not addressed.  This bad transfer happens for many reasons, including: the arrogance and/or laziness of doctors, the disorganization of medical offices, the inaccesability of tests and labs, the ridiculous documentation requirements which hide useful information, and the volume-driven foundation of the system, which discourages taking extra time to communicate or find the appropriate information.

So my patient has to live with his pain while I try to figure out how to treat a condition I am not supposed to be treating.  In this case it is only pain; in some cases it is worse.  I every case, it costs the system a lot of money and makes the likelihood of a good outcome much lower.



Letter to Patients Regarding Pain Medications

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:

Dear <Patient>

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.