Doctors and pain medications

An interesting piece by John Tierney in today’s New York Times made me reflect on the ongoing battle between physicians trying to help their patients deal with pain, drug seekers who are constantly trying to work physicians for narcotic pain medicines, and the members of various branches of law enforcement who are waging the war on drugs.

The piece entitled Punishing Pain is about a 46 year old man named Richard Paey who suffers from multiple sclerosis and developed chronic pain as the result of an automobile accident. Over time his pain became unbearable and he sought relief from a number of physicians. His intake of pain medicines increased and

as he took more pills, Mr. Paey came under surveillance by police officers who had been monitoring the prescriptions. Although they found no evidence that he’d sold any of the drugs, they raided his home and arrested him.

What followed was a legal saga pitting Mr. Paey against his longtime doctor (and a former friend of the Paeys), who denied at the trial that he had given Mr. Paey some of the prescriptions. Mr. Paey maintains that the doctor did approve the disputed prescriptions, and several pharmacists backed him up at the trial. Mr. Paey was convicted of forging prescriptions.

The upshot is that the wheelchair-bound Mr. Paey refused a plea bargain because he felt he was innocent and refused to plead guilty to a crime he didn’t commit. He was sentenced under the mandatory drug sentencing laws to 25 years in prison, where he resides today. Ironically, he’s getting better medication for his pain in prison than he was before his incarceration because the State of Florida is supplying him with a morphine pump, which allows him to increase his own medication as the pain increases.

It’s been my experience that most doctors tend to under medicate for pain. My wife and I have a running joke about doctors and pain medications—we can always tell what a doctor has experienced himself (or herself) by the medications this physician prescribes for others. If, for example, we come across a doctor who writes heavy doses of pain medications for migraine headaches, we can be pretty sure that that physician has herself been afflicted with migraine headaches. If a doc writes heavy pain meds for patients with back pain, we know that doc has himself experienced bad back pain. It would be great if all physicians—yours truly excluded—could experience the whole range of pains from various disorders so that they could prescribe accordingly.

My first tour of duty as a brand new surgery resident was on the general surgery ward that handled all the burn patients. Once they’ve been resuscitated from the initial trauma of the burn, the major risk to burn patients is infection. At that time we tried to stave off infection by changing our patients’ burn dressings daily (and sometimes even twice daily), a lengthy process that sometimes took over an hour and was in most cases unbearably painful for the patients. I was appalled by the incredible pain we inflicted on these people, and set out to do something about it. (I’m not trying to cast myself in the role of a hero here. I didn’t have to fight the administration or anyone else to do this. In fact, no one really cared. I just thought that medicine had advanced a long way since the Middle Ages and that since we had the medications at our disposal to stop the pain, why should these poor patients have to endure the agony of these dressing changes.) I went down to the anesthesia department and talked to some folks there who designed an injectable cocktail for me. We started anesthetizing the patients, then changing their dressings. I believe it made a huge difference in their lives. Unfortunately, when I rotated off the burn service, I think the incoming residents went back to the previous practice. It’s been so many years since all this happened that I have no idea what is done now.

The point of this is that one of the many things medical science can point to with pride is the development of drugs to stop pain. We need to make better use of this technology. Just a century and a half ago patients were faced with the choice of undergoing surgery without anesthesia (because it didn’t exist) or dying from the disease they were suffering. Now sophisticated anesthesia is available so that surgery is totally painless. And oral and injectable painkillers keep discomfort to a minimum during the recovery period. So, why don’t we use them more in an outpatient setting?

Doctors are reluctant to prescribe pain medications for a couple of reasons. All of us who have been in practice for any length of time have been hit up by drug seekers. My first experience was with a badly scarred thirty something guy who had by his telling been in a railroad accident. He certainly had the scars to prove something bad had happened to him. He came in with an empty prescription bottle for Demerol, a potent narcotic pain medication. The doctor’s name on the label was a well respected physician in town. The patient told me he was in extreme pain from all his previous injuries, and that his regular doctor—the guy on the label—was out of town. (I tried to call this other doctor, but got his answering service.) I finally relented, gave the guy a prescription for more Demerol, and sent him on his way with instructions to see his regular physician soon. Later the receptionist told me that the guy told her he left his checkbook in the car, went out to get it, and never came back to pay for his office visit. Within days after this incident we started seeing all kinds of people in the clinic with “severe” pain of one kind or another who wanted Demerol. Suspecting what had happened, I called a friend at the police department, who confirmed my suspicions. As soon as I read off the names of the people who had come in, he identified them as drug users and drug dealers. Apparently word of an easy mark physician spreads pretty rapidly throughout the drug using underbelly of a city. A police team went out and arrested them all for theft of services (they had all devised some way to get out of the clinic without paying). They all plead their offenses down, got off with a fine, word quickly got around, and we were never bothered again. An experience like this one, however, makes physicians leery about prescribing pain medications. And virtually all physicians in any kind of primary care setting have the same kind of stories to tell.

The second reason physicians are reluctant to prescribe pain meds is law enforcement. Let’s suppose I had taken the easy way out with all these drug seekers and had just given them their prescriptions and avoided the conflict. Sooner or later one or more of them would have been caught doing something, and they would have had scripts for Demerol with my name on them. Then the police would have been beating on my door wondering why I had given these prescriptions to all these people who were obviously in good health. I’ve had a number of physician friends that this has happened to. I even had one physician friend who had a long-awaited family vacation ruined because he was subpoenaed by the police to testify in one of these cases.

As a physician you find yourself caught up in trying to keep drugs out of the hands of drug seekers, keeping the police off your back, and medicating those who truly need it. Problem is in this scenario, it seems the patients—just like the guy in the above New York Times article—always end up the losers.

What’s the solution? I wish I knew for sure. If I had my way I would legalize drugs simply because legalizing drugs would at least remove the profit motive. I believe the entire war on drugs has been an utter disaster, serving only to relieve us of a lot of our freedoms under the guise of doing something noble. I have this argument often with my father, who is a firm believer in the war on drugs. I say my piece about the abridgment of freedoms, he counters with, “Yeah, well how many of your freedoms have been lost? What is it that you want to do that you can’t do because of the war on drugs? How have you been impacted directly?”

I can only answer that I haven’t been impacted directly. I don’t need to go get $10,000 out of the bank, but if I wanted to, I couldn’t without filling out a form, thanks to the war on drugs. That annoys me. When we got back from Europe a couple of weeks ago, we had to run the gauntlet of drug sniffing dogs as we got off the plane. That annoys me. (It especially annoys me when those resources could be better spent on bomb sniffing dogs that smell people before they get on the plane.) The fact that all these things annoy me isn’t the point, however. The point is that (at least in my opinion) the loss of freedoms is a slippery slope, and once started down it’s often difficult to stop.

I doubt seriously that Mr. Paey ever thought he would find himself behind bars for 25 years for seeking relief from his pain

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