The Pain Med Conundrum

by Danielle Ofri
New York Times op-ed

My patient Mr. W. wheeled himself into my office for a checkup. He’d lost a leg to diabetes and was also juggling hypertension, obesity, vascular disease and elevated cholesterol. He was an amiably cranky fellow in his mid-60s who’d used heroin in the past though had been clean for decades.

As we finished up and I handed him his stack of prescriptions, he said, “Oh, by the way, Dr. Ofri, I was wondering if you could prescribe me the oxycodone I use for my back.”

Oxycodone? In the six months I’d known him, I hadn’t been aware that he was taking narcotic pain medication.

“I’ve been getting it for years from my pain doctor in the Bronx, but that clinic closed,” he explained. “So now I’ve got to get it from my primary care doctor.”

He told me about his years of back pain from a construction injury. He could list the other meds and physical therapy he’d tried; oxycodone was the only thing that worked consistently.

Here it was again: the dreaded pain conundrum. A patient requests a strong pain medication and the doctor has to figure out whether the request is legitimate. This is an aggravating situation on many levels. On the individual level, there are the immediate issues of trust — do I trust Mr. W.’s story, and, conversely, how will my decision affect Mr. W.’s trust in me?

Then there is the larger issue of how we doctors treat pain in general. A 2011 report from the Institute of Medicine highlighted how poorly the medical field handles pain. Undertreating pain, we are admonished, violates the basic ethical principles of medicine. On the other hand, we are lambasted for overprescribing pain medications, enabling addicts and creating an epidemic of overdose deaths.

What are doctors to do? Pain is a subjective symptom. There is no instrument to indicate its severity. All that a doctor has is the patient’s word.

For patients with chronic pain, especially those with syndromes that don’t fit into neat clinical boxes, being judged by doctors to see if they “merit” medication is humiliating and dispiriting. It’s equally dispiriting for doctors. This type of judgment, with its moral overtones and suspicions, is at odds with the doctor-patient relationship we work to develop.

As Mr. W. and I sat there sizing each other up, I could feel our reserves of trust beginning to ebb. I was debating whether his pain was real or if he was trying to snooker me. He was most likely wondering whether I would believe him or if I would be biased because he was an African-American man with a history of drug use. Studies show that minorities are consistently undertreated for pain.

There were certainly a few red flags in Mr. W.’s story, but his circumstances were also entirely plausible. I asked as many questions as I had time for, but we were already running late. It could take weeks to get an appointment in a specialty pain clinic, and restarting physical therapy wasn’t easy with his insurance. In the end I had to decide whether I was more ethically comfortable denying meds to a patient in legitimate pain or inadvertently supplying an addict.

Realistically, a drug addict denied will almost always find a way to get meds, but a person with real pain truly suffers. And so despite some misgivings, I gave Mr. W. a prescription for oxycodone and scheduled another visit to discuss his pain issues in more depth.

The challenge Mr. W. presented was typical: pain that cannot be “objectively” verified; complicated circumstances that do not fit easily into a handy treatment algorithm; a shortage of pain specialists; insurance plans that cover prescriptions more readily than they cover physical therapy, acupuncture or massage; and a reimbursement system that does not prioritize thorough discussions.

Some attention is beginning to be paid to this problem. For example, New York State has created a registry for narcotic prescriptions so doctors can check for patterns of abuse. This is helpful, though the laborious mechanics of the system are a major impediment. Additionally, people who are determined to outfox the system can always fill their prescriptions in neighboring states.

Clearly, we need more pain management specialists and better insurance coverage for nonpharmacological treatments and extended doctor-patient discussions. It is also critical to address the aggressive pharmaceutical marketing that did much to create the mess we are in now.

But the vast majority of pain medication decisions take place during ordinary office visits like Mr. W.’s, within a swirl of imperfect circumstances. A solid doctor-patient alliance is a critical factor for good health. But when patients feel judged by their doctors, and doctors are exhorted to not undertreat pain and simultaneously pilloried for overprescribing pain meds, this relationship can be sabotaged. That isn’t good for anyone’s health.