The elements of pain care that the guidelines don’t address



You are probably one of the million+ physicians who received a letter from the Surgeon General urging us to use opioids judiciously,1 and you are likely familiar with the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.2 (See JFP’s Opioids for chronic pain: The CDC’s 12 recommendations,” 2016;65:906-909.) Most of these recommendations are common-sense practices, such as reducing doses, using alternative medications and treatments, monitoring prescribing through state databases, conducting random drug tests, consulting pain and addiction specialists, and establishing clear treatment goals.

But the guidelines only go so far. They don’t address the empathy, perseverance, and insight needed to stick with these patients and oversee their care. And they don’t directly address the patients who are already taking opioids for chronic pain when they arrive at our offices. Despite nearly 40 years of practicing family medicine, I can count on one hand the number of patients for whom I initiated opioid medication. Yet I have managed many patients with chronic pain who were already on hefty doses of narcotics when they became my patients. Rather than refuse to care for them, we should seek to understand their story, continuously try other medications and therapies, repeatedly attempt to reduce dosages, and frequently check substance databases.

It's no wonder some of us just say "No" to caring for patients with chronic pain.Following the guidelines is no guarantee that our prescribing practices won’t be called into question. I have seen excellent family physicians censured by state licensing boards unjustifiably. One colleague was accused by a patient of “getting him addicted,” only after the physician refused to continue prescribing narcotics. Based on this single complaint, the physician had his license temporarily revoked with no due process whatsoever. He got his license back after an appeals process that took several months, cost many dollars, and inflicted significant emotional trauma. No wonder some of us just say “No” to caring for patients with chronic pain.

Perseverance and motivation. I remind myself that good, well-intentioned, and careful primary care physicians are NOT the cause of this epidemic. I encourage you to stick with these patients (lest they turn to the streets to obtain heroin laced with fen­tanyl), and look for sources of motivation. You may be motivated, as I was, by a physician’s story in JAMA about his 49-year-old younger sister, a vibrant, accomplished, caring woman whose chronic pain led to her death in a jail cell after she became combative in the ED.3 Had she been treated as a patient with a chronic illness, rather than a criminal with a character flaw, I suspect she would be alive today.

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How to discuss Vivitrol with the ambivalent patient

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