In my good old days as a drug dealer, you came to me with enough pain and I gave you the narcs. Percocet, Vicodin, OxyContin, whatever — the deal was a private one between you (the patient) and me (the doc). Those days are gone, replaced now by an era when outsiders — government agencies, police, other physicians and lawyers — are in the exam room with us whenever we treat your pain with narcotics.
The rules are changing because of growing recognition that what you and I do in the office is contributing directly to America’s epidemic of narcotic addiction. The more narcotics I prescribe to you the more chance some of them end up on the street for sale to addicts, or that you become pathologically addicted.
As a result, your pain treatment is no longer just about you and me, but also about present and future addicts. The two of us are now obliged to treat your pain in a way that limits our potential contribution to this national epidemic. Toward that end, in order to keep those outside the exam room looking unhappy and minimize the patient’s risk of addiction, patients who are taking narcotics on a chronic basis should now have:
• A signed pain contract with their primary care provider, or PCP, describing the obligations of the patient to comply carefully with the rules of their treatment program.
• Random urine drug testing several times each year to ensure patients are taking their medicine and not abusing illegal drugs.
• Random counts of their narcotic pills to make sure pills are not being taken faster than prescribed, sold or given to someone else.
• A comprehensive pain program, including regular visits with a pain specialist, psychologist, physical therapist and PCP.
No other patient relationship is so controlled and controlling. Unique among patients, those on chronic narcotics cannot simply be trusted; proof of compliance with the treatment plan is required, and sometimes rightly so. In recent years, such patients of mine have lied to me about their narcotic use, forged changes on prescriptions I wrote for them, embezzled money to buy extra narcotics on the street and killed themselves with an overdose of their pills.
Understandably, then, failure to follow this program can get patients cut off from their pain pills and fired by their PCP. Good luck to those patients, because few other PCPs want more patients on narcotics in their practice. Rather than deal with the complexities of treatment, the legal risks, the constant battle with patients about how much narcotic they can take, fights with patients who break the rules, and the occasional patient who lies about their pain in order to get drugs for an addiction or street sale, many PCPs have just stopped prescribing narcotics for chronic pain patients.
The patient is not the only one at risk. Failure to follow these emerging rules, or prescribing narcotics carelessly, can cost a physician his medical license and livelihood.
All of this makes the prescribing of narcotics — especially for chronic pain — the most frustrating, nerve-wracking, professionally risky thing I do. It makes being a patient who needs narcotics for the simple, sweet relief of pain frustrating, burdensome and often demeaning.
To take the sting out of this, and before the requirements of treatment with narcotics become more burdensome, we need statewide and national treatment protocols that de-emphasize narcotics for common pain problems, and systematic implementation of such protocols in emergency departments and primary care. We need patient and PCP education about the risk of narcotics, how to improve non-narcotic management of pain and about why management of pain with narcotics has more rules than parole.
Such changes would help make PCP relationships with the patient on narcotics less of a potentially constant battle, less likely to add to the flow of illegal pills to the street and less like having our teeth constantly drilled.
Otherwise, the growing professional pain of narcotic management will cause more and more PCPs to simply refuse to manage patients who need narcotics on a chronic basis and dump that burden on their colleague across town. The idea has more appeal to me all the time.
Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems and is on the staff of several hospital emergency rooms in the region. He is also the interim CEO at Blue Hill Memorial Hospital.