Residents' Wisdom Regarding Narcotics
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《美国整骨期刊》
Oregon Health and Sciences University Gabriel Park Family Medicine Center Portland, Ore
I read with interest the letter by Dr Todd Fredricks in the November 2005 issue of JAOA—The Journal of the American Osteopathic Association ("Doctors' dilemma: prescription pain medications." 2005;105:493–495). I agree that there are many patients who are being prescribed narcotics for relatively minor medical concerns and that it is relatively easy for these patients to find physicians who will fill prescriptions for controlled substances. The improper prescribing of pain medications can cause a number of problems for physicians and patients.1–3
One dilemma commonly confronted by faculty members in residency training programs is how to advise residents to treat a patient who has a history of escalating narcotic usage with no definite or objective physical findings. During the Difficult Case Discussion, a resident case conference held in Portland, Ore, in November 2005, I, as a faculty member, presented the case of a patient of mine who had been using narcotics (acetaminophen/hydrocodone [Vicodin]; acetaminophen/oxycodone [Percocet]; methadone [Methadose/Dolophine]; oxycodone [OxyContin]) for a sustained period. I then asked the residents to "guide" me through a strategy of treating this patient.
At the beginning of the conference, I asked the residents to carefully consider my patient's medical history, the results of his physical examination, and the symptoms he described at each of his encounters with me. I also let the residents know that I was in a bit of a quandary as to how to proceed with my care for this patient.
The patient was a 50-year-old man who had symptoms of neck, shoulder, and back pain for an unknown duration. He told me that the pain began after a series of automobile accidents. His first visit with me came after he had "helped a friend move a refrigerator." This activity prompted a trip to the emergency department in which he was treated for a flare-up of his neck pain. The narcotic and muscle relaxant prescribed by the emergency department physician was not providing enough relief, however. He said that he came to see me because he wanted something a little stronger.
The patient told me that he had recently been discharged from another physician's care for repeatedly missing or being late for his appointments. He said he had also been discharged from a pain specialist's care after testing positive for cannabinoids in his urine. Since being discharged, he had been obtaining his pain medication by ordering it from certain Web sites. During this first visit with me, he requested a small increase in his pain medication, asking if he could have a prescription for two Vicodin pills every 4 hours (compared with his existing prescription of one pill every 4 hours).
At our next meeting, which came alarmingly just 10 days after our first encounter, the patient told me that he was about to run out of his Vicodin. He pointed out that he was taking his pain medication exactly as I had prescribed—one to two pills every 4 hours. However, he added, he was taking a total of 12 pills per day because, "I never sleep more than 4 hours at a time." In fact, he told me with a straight face that he probably could make due with a prescription for 320 Vicodin per month or a change in his prescribed medication from Vicodin to Percocet or OxyContin.
A brief trial of OxyContin, which is a longer-acting opioid than Vicodin, failed to result in decreased usage of Vicodin by the patient. He returned to see me, reporting that he had again been in automobile accident and was in worse pain than before. He also told me that he had not called the police or emergency services (911) despite suffering a 10-minute loss of consciousness. During this third visit, we again discussed options for nonnarcotic pain relief (eg, anti-inflammatory medication, osteopathic manipulative treatment, physical therapy, psychological counseling, neurosurgery). I could not understand why this patient with a history of chronic pain was moving a refrigerator. Nor could I understand why he did not call 911 after his stated loss of consciousness.
Because pain is an inherently subjective experience (pain has been defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"),4 my patient's requests for narcotic pain relief presents a dilemma. It is complicated by the fact that he characterized his experience of pain as a cause for significant disability in his life. However, he refused every other therapeutic modality, including osteopathic manipulative treatment, that I suggested. So, I asked the residents at the conference, "How would you treat this patient"
I was pleased to hear the following suggestions offered by the residents in response to my question:
You are not obligated to prescribe this patient narcotics; you have enough doubt about his motives to refuse to supply him with these medications. Tell him that you are not going to provide him any more controlled substances until you can better understand his problems.
Explain to the patient that pain is a physiologic response to injury that can be further intensified if he is depressed. Perhaps this patient could benefit from other forms of treatment (eg, antidepressants, psychotherapy), rather than narcotics.
The patient should sign a narcotic contract in which he agrees to specific parameters for his behavior.
I discussed these suggestions with my patient at our next—and final—visit, and he responded by telling me that he saw no need to continue as my patient. He said that if I was not going to continue to prescribe him the pain medications that he was requesting, he would find someone else who would. While I don't typically relish losing a patient, I was somewhat relieved that he was quitting my practice based on refusing my offer to provide him alternative treatments for his pain. Hopefully, the next physician that he contacts will request to see his past medical records.
For physicians who find themselves with similar patient situations, I have a number of recommendations. The advice that the residents gave at the conference is well worth considering. Interactive discussions among healthcare providers can serve as an opportunity to use a "team approach" rather than an individual approach in determining patient care. In addition, it is important that physicians at all levels of experience be exposed to quandaries similar to this so that they don't become unwitting participants in drug seekers' efforts to obtain narcotics.
I thank Dr Fredericks and the JAOA for bringing this subject to light and allowing a dialogue to occur.
References
2. Meier B. The delicate balance of pain and addiction. New York Times. November 25, 2003; Science section.
4. International Association for the Study of Pain Task Force. Merskey H, Bogduk N, eds. Classification of Chronic Pain. 2nd ed. Seattle, Wash: IASP Press; 1994:209–214. Available at: http://www.iasp-pain.org/terms-p.html. Accessed March 9, 2006.(MARK L. SHATSKY, DO, Assi)
I read with interest the letter by Dr Todd Fredricks in the November 2005 issue of JAOA—The Journal of the American Osteopathic Association ("Doctors' dilemma: prescription pain medications." 2005;105:493–495). I agree that there are many patients who are being prescribed narcotics for relatively minor medical concerns and that it is relatively easy for these patients to find physicians who will fill prescriptions for controlled substances. The improper prescribing of pain medications can cause a number of problems for physicians and patients.1–3
One dilemma commonly confronted by faculty members in residency training programs is how to advise residents to treat a patient who has a history of escalating narcotic usage with no definite or objective physical findings. During the Difficult Case Discussion, a resident case conference held in Portland, Ore, in November 2005, I, as a faculty member, presented the case of a patient of mine who had been using narcotics (acetaminophen/hydrocodone [Vicodin]; acetaminophen/oxycodone [Percocet]; methadone [Methadose/Dolophine]; oxycodone [OxyContin]) for a sustained period. I then asked the residents to "guide" me through a strategy of treating this patient.
At the beginning of the conference, I asked the residents to carefully consider my patient's medical history, the results of his physical examination, and the symptoms he described at each of his encounters with me. I also let the residents know that I was in a bit of a quandary as to how to proceed with my care for this patient.
The patient was a 50-year-old man who had symptoms of neck, shoulder, and back pain for an unknown duration. He told me that the pain began after a series of automobile accidents. His first visit with me came after he had "helped a friend move a refrigerator." This activity prompted a trip to the emergency department in which he was treated for a flare-up of his neck pain. The narcotic and muscle relaxant prescribed by the emergency department physician was not providing enough relief, however. He said that he came to see me because he wanted something a little stronger.
The patient told me that he had recently been discharged from another physician's care for repeatedly missing or being late for his appointments. He said he had also been discharged from a pain specialist's care after testing positive for cannabinoids in his urine. Since being discharged, he had been obtaining his pain medication by ordering it from certain Web sites. During this first visit with me, he requested a small increase in his pain medication, asking if he could have a prescription for two Vicodin pills every 4 hours (compared with his existing prescription of one pill every 4 hours).
At our next meeting, which came alarmingly just 10 days after our first encounter, the patient told me that he was about to run out of his Vicodin. He pointed out that he was taking his pain medication exactly as I had prescribed—one to two pills every 4 hours. However, he added, he was taking a total of 12 pills per day because, "I never sleep more than 4 hours at a time." In fact, he told me with a straight face that he probably could make due with a prescription for 320 Vicodin per month or a change in his prescribed medication from Vicodin to Percocet or OxyContin.
A brief trial of OxyContin, which is a longer-acting opioid than Vicodin, failed to result in decreased usage of Vicodin by the patient. He returned to see me, reporting that he had again been in automobile accident and was in worse pain than before. He also told me that he had not called the police or emergency services (911) despite suffering a 10-minute loss of consciousness. During this third visit, we again discussed options for nonnarcotic pain relief (eg, anti-inflammatory medication, osteopathic manipulative treatment, physical therapy, psychological counseling, neurosurgery). I could not understand why this patient with a history of chronic pain was moving a refrigerator. Nor could I understand why he did not call 911 after his stated loss of consciousness.
Because pain is an inherently subjective experience (pain has been defined as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage"),4 my patient's requests for narcotic pain relief presents a dilemma. It is complicated by the fact that he characterized his experience of pain as a cause for significant disability in his life. However, he refused every other therapeutic modality, including osteopathic manipulative treatment, that I suggested. So, I asked the residents at the conference, "How would you treat this patient"
I was pleased to hear the following suggestions offered by the residents in response to my question:
You are not obligated to prescribe this patient narcotics; you have enough doubt about his motives to refuse to supply him with these medications. Tell him that you are not going to provide him any more controlled substances until you can better understand his problems.
Explain to the patient that pain is a physiologic response to injury that can be further intensified if he is depressed. Perhaps this patient could benefit from other forms of treatment (eg, antidepressants, psychotherapy), rather than narcotics.
The patient should sign a narcotic contract in which he agrees to specific parameters for his behavior.
I discussed these suggestions with my patient at our next—and final—visit, and he responded by telling me that he saw no need to continue as my patient. He said that if I was not going to continue to prescribe him the pain medications that he was requesting, he would find someone else who would. While I don't typically relish losing a patient, I was somewhat relieved that he was quitting my practice based on refusing my offer to provide him alternative treatments for his pain. Hopefully, the next physician that he contacts will request to see his past medical records.
For physicians who find themselves with similar patient situations, I have a number of recommendations. The advice that the residents gave at the conference is well worth considering. Interactive discussions among healthcare providers can serve as an opportunity to use a "team approach" rather than an individual approach in determining patient care. In addition, it is important that physicians at all levels of experience be exposed to quandaries similar to this so that they don't become unwitting participants in drug seekers' efforts to obtain narcotics.
I thank Dr Fredericks and the JAOA for bringing this subject to light and allowing a dialogue to occur.
References
2. Meier B. The delicate balance of pain and addiction. New York Times. November 25, 2003; Science section.
4. International Association for the Study of Pain Task Force. Merskey H, Bogduk N, eds. Classification of Chronic Pain. 2nd ed. Seattle, Wash: IASP Press; 1994:209–214. Available at: http://www.iasp-pain.org/terms-p.html. Accessed March 9, 2006.(MARK L. SHATSKY, DO, Assi)