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?   (read the full New York Times Op-Ed)