The goal is for pain management patients to have the best life possible while dealing with their pain
http://www.clinicaladvisor.com/the-waiting-room/pain-management-in-primary-care/article/713073/
I work in primary care as a Family Nurse Practitioner, but there are days I feel more like I am primarily a pain management provider who also practices primary care. Prescribing chronic opioids on a regular basis is not something I particularly enjoy, and there are times I feel like a little piece of my soul dies with every prescription. To be clear, I do not doubt that my patients are in pain (or at least believe they are in pain). In many cases I feel as though these patients were placed on chronic opioids inappropriately, and it has become too difficult for them to stop. Providers may think, “We’ve done nothing for your pain, and we’re all out of ideas, so here are some opioids.”
When I see my patients on chronic opioid therapy, I talk to them about why they are on the medication, how long they’ve been taking it, and how they feel about being prescribed opioids. Many patients would like to take less — decrease their pill burden — but I am finding that some patients are afraid of being in pain if they stop medication completely. Thus, a vicious cycle begins.
Now, that’s not to say that pain management in primary care isn’t entertaining. I realized at one encounter that I’ve been missing out on a lot of interesting parties. One patient I saw stated that the reason methamphetamine was present in his urine drug screen was because he snorted a line of meth at a party during a game of truth or dare.
Another patient said that the reason she was discharged from a pain management program was because on her way to the appointment, she had stopped for coffee, and some teenagers might have poured methamphetamine in her cup when she wasn’t looking. Of course, the pain management provider just wouldn’t listen to reason.
Once, I almost had to call the Vet for consultation. A patient explained that the reason for his discharge from pain management was because the pet cat found the bottle of oxycodone in a pillowcase and swallowed all of the pills. No fear, the kitty is ok.
When I share these stories with other peers, the question that arises is, how do we keep our objectivity? What prevents us from becoming even more jaded and thinking everyone who asks for opioids is just a ‘pill-popper’?
Well, my last patient is a long time chronic pain patient who has been on incredibly high doses of opioids. After almost 2 years of dose adjustments and discussions about other options to treat his pain, he tells me today that he wants to stop all opioids and explore other options. He admits he was afraid of pain, but the side effects of opioids have become too much to handle.
So what is the answer? All I can suggest is for clinicians to have patience and an open avenue of discussion with patients about the expectations of pain management in primary care. At no time is it acceptable to abandon patients, or treat them as a ‘junkie.’ The goal is for pain management patients to have the best life possible while dealing with their pain.
Filed under: General Problems
In the U.S. the general consensus seems to be that most primary care practices want nothing to do with chronic pain patients. They generally refer the patient to “pain specialists”. Pain specialists either prescribe physical therapy or perform some type of injection or nerve block. These injections, obviously, only last a limited amount of time then have to be repeated. Forever. And the patient has to be out of commission for a week or more after the procedure. Many patients cannot take the time off needed until the ablation or block begins to work. Also there are side effects and complications of any procedure like this. The answer is not to prescribe Tylenol or ibuprofen. The side effects of chronic use of these two medications are well known. The answer is to fast track research on new, non-addictive but effective pain medications for long term use. In the meantime, the CDC and DEA need to back off playing doctor and get out of the physicians practices.
Drugs should be legalized, in the same way that alcohol (ethanol) is legal. You and I should not have to go to a medical doctor for permission to purchase and consume psychoactive substances. That may sound crazy, because we are all so used to the status quo (1914 Harrison Narcotics Tax Act, 1961 Single Convention on Narcotic Drugs, Drug War, etc.).
However, we are increasingly recognizing how ill advised drug prohibition is. The Global Commission on Drug Policy is calling for changing the UN convention to allow member states to experiment with different models of regulation (other than prohibition). Both the British Medical Journal and The Lancet have put their toes into the water of legalization (meaning . . you and I do not have to go to a clinician for “permission,” aka “prescription.”)
Fact is, that most people who use illicit drugs (and licit) for recreational purposes do not have a drug problem. The vast majority go to work, mow their lawn, pay their taxes, take care of their children, etc. Sometimes they even become President of the United States of America. Our last three former Presidents all used illicit drugs when they were younger (if they still do, they’re highly unlikely to admit it). Abuse, addiction, and overdose are the exception, not the rule, when it comes to the recreational (much less medical) use of psychoactive substances.
leap.cc
drcarlhart.com
globalcommissionondrugs.org
Sorry to have left out the references. Here they are.
The Lancet, “Public health and international drug policy”
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00619-X/abstract
“The war on drugs has failed: doctors should lead calls for drug policy reform”
http://www.bmj.com/content/355/bmj.i6067
“The answer is to fast track research on new, non-addictive but effective pain medications for long term use.”
I just want to point out that this is not the answer to reducing addiction and abuse rates. Chronic pain patients are not the cause of the increased rates of opioid abuse. The large majority of addictions are triggered by recreational use, not medicinal use, of opioid-based medication.
Furthermore, over 90% of addictions begin in the early teen years which is when a person is more likely to experiment with intoxicating substances.
Regardless of what is available on the pharmaceutical market, opioids of all kinds (including prescription medication) will ALWAYS be available via black market. The black market is always glad to offer substances that have been excessively restricted or banned by the government.