First, I want to say I greatly appreciated your comments about pain management within the primary care setting and the potential troubles it can cause for our patients and ourselves. I can certainly relate first-hand in two ways: first as a health care professional and secondly as a chronic, severe pain patient myself. I am a Certified Registered Nurse Practitioner working in Family & Community Medicine, board certified in family health and psychiatry; I also hold a doctorate--Doctor of Nursing Science (DNSc)--and two Master of Science in Nursing degrees, one in Nursing Education and the second in Advanced Practice Nursing - Family Health. I have been a CRNP for about 15 years and an RN, in many different roles including teaching, management, counseling, etc., for over 30 years.
As such, I have seen more than my share of abhorrent, "drug-seeking" behavior in patients across the lifespan, but unfortunately, I have also seen a gross negligence in the treatment of pain, particularly within the primary care setting. I am totally for other treatment modalities for chronic pain such as exercise and lifestyle modification, physical therapy, biofeedback, acupuncture, TENS, corticosteroid/anesthetic injections and the list continues. But the fact of the matter is, these therapies are sometimes inadequate or ineffective and the use of opioid analgesics should always be an option. However, unfortunately, too many physicians, PAs and NPs are too afraid to prescribe opioids; afraid of persecution, being investigated by the DEA and having their DEA number revoked, afraid of having their state license suspended or revoked, afraid of going to jail, etc. And these can be, at times, real fears--trust me, I don't want any of those things to happen to me, either. But the fact of the matter remains, if we prescribe opioid pain medication within a normal scope for the practice of medicine, if there is an established clinician/patient relationship, if the risks and benefits have been fully discussed with the patient, if other non-narcotic treatments have been tried first (NSAIDS, TCAs, anticonvulsants, etc.), then there really should be no fear or hesitation to utilize these medications.
In your article, you said "most doctors (including me) hate narcotic pain medications - especially the short-acting ones," and while I am not a physician, I do have prescriptive authority--and I do prescribe narcotics--and for myself, I will have to respectfully disagree with that statement. In reality, I have no problems prescribing opioid analgesics when they are warranted--in my opinion, opioids are the most effective treatment for pain we have available. They are reliable, true opioid agonists have no ceiling effect, they generally don't produce many side effects--at least ones which aren't manageable--most have been around for 50-100+ (morphine for over 200) years and, like I said, they work. In my practice, for patients receiving long-term opioid treatment, we have a "narcotics contract" which they sign to agree to use only one pharmacy, receiving their prescription(s) from only our practice, acknowledging not to call for refills on the weekend or end of the day, the possibility of random toxicology screens, etc. And no, a signed piece of paper isn't going to prevent abuse, addiction, diversion, etc., but I think it does help and the patient is fully aware of possible consequences should they violate the terms of the contract.
I have always said--and I think every clinician could benefit from a similar mindset--if on any given day I have 10 patients who received a prescription for an opiate, and of those 10 patients, only one actually had moderate to severe pain and truly *needed* the medication, then at least I did not refuse that patient the treatment they need and deserve. Now, I'm not saying we should hand a prescription for hydrocodone/APAP or oxycodone/APAP, etc. to every patient who complains of aches and pains, but as you mentioned sometimes it's hard to decipher who *needs* it and who just wants it for the euphoric high. If the question remains--if a clinician can't decide if the person needs it or just wants it--we have opioids of all strengths; I say it's better to give them codeine/APAP 30/300 mg (Tylenol #3) Sig: i tab. po q4-6h prn, Disp: #20, since codeine is one of the weakest opiates (but would still provide *some* relief), than to tell them to take ibuprofen and have them suffer because they really are in pain, but we, the medical professional, couldn't decide for them if their pain really deserved to be treated. Hydrocodone/acetaminophen and oxycodone/acetaminophen are both available in 2.5/500 mg and 2.5/325 mg doses, respectively, which could be alternated with 600 mg ibuprofen. So if the patient is questionable, there are low-dose options, and the quantity dispensed can be conservative, but at least it's *something* and will take the edge off, so to speak, in case that patient really is in pain and the clinician just "read" them wrong. We're taught if a patient asks for "Vicodin," "Percocet," "hydromorphone," or whatever the case may be--if they ask for a drug by name, then we're taught they are drug-seeking--but for all I know, this patient had an abscessed tooth once, was prescribed Vicodin by their dentist and it worked well for them without any GI upset, dizziness or too much drowsiness; it doesn't have to mean they're addicted to Vicodin. Like you said, it really is a fine-line, but unfortunately, too many clinicians err on the side of caution and say "no" rather than say "okay, I'll give you a prescription for a mild opiate, 15 tablets, and I want to see you back in a few days if there is no improvement--I won't issue any refills without seeing you again."
As I mentioned, I, myself, am a chronic, severe pain patient from a screwed up back and right knee. I actually take morphine sulfate extended release (MS Contin) 30 mg b.i.d. and also oxycodone IR 10-15 mg q4h and it's enough to allow me to get out of bed and walk, function normally, have a life, practice medicine, have hobbies, etc. I am on fairly potent medications at relatively high doses, but unfortunately, I need those medications to have a normal life. And because of this, I can certainly relate and sympathize with my pain patients on a whole new level that, at one point, I could not and at which most clinicians will also never be able to. It is my hope that one day every clinician is more sympathetic and understanding like yourself and realizes pain is a real thing--it needs real (sometimes strong) treatment, and not everyone is out to just get high at their clinician's expense. The fear and hesitation of prescribing opioid analgesics needs to be erased, but instead, it gets worse with every passing day. And that, to me, is the epitome of practicing "cover my ass medicine" which only benefits and protects the clinician while our patients suffer...and that's not okay, that is not the definition of our job.
I appreciate the time in reading my comments and thoughts; and, again, I greatly appreciated your article and your blog in general--it contains some very informative, well-composed information, thoughts and insight into medicine and primary care.

Warm wishes,
Dr. Diane F.

First I want to say thank you for your soft-heartedness. Your patients are blessed.

Years ago when I was being shuffled from specialist to specialist looking for the cause of my chronic pain, I had a neurologist tell me "I know the kind of person you are. You want me to tell you you have a brain tumor, but I won't! But you are the kind of person who will sue me if it turns out you have one." Huh! I was young and in pain. Brain tumor had not crossed my mind. I just wanted help.

He sent me to a pain specialist and there I did find help. She diagnosed me with Fibromyalgia and sent me through pain rehabilitation. At the pain clinic I saw many patients who were learning to cope (with the cognitive behavior approaches Bronnie mentions) without the use of the prescription drugs they had come to depend on. In fact I was one of the only patients in the program who did not have to be weaned from pain killers. I am thankful I never went down that path, and although some days it is not easy, I try my best to manage my pain without narcotics.

It might not be fun to be the one where the buck stops, but would you rather it stopped at someone with less compassion? Someone like that awful neurologist who was simply mad at me because I was his last patient of the day, and he was running late for a dinner? Somehow I doubt you would.

You know, there are other options - seeing a really good interdisciplinary pain management team can mean being given neither anaesthetic procedures or medications, but simply a cognitive behavioural approach to developing coping strategies to live life rather than be controlled by pain. Oh, and it's got a pretty good evidence base over 30-odd years too, and no side effects (or calories!).

BTW having evidence of a nociceptive source for pain doesn't mean those who don't have less genuine pain. In fact, having no 'obvious source of pain' probably means they have even more distress and difficulty accepting the chronicity of their pain.

Addiction for those who have chronic pain and use opioids is not typically a problem - but tolerance is. Tolerance develops to narcotics, and means an increased dose is required to achieve the same degree of pain relief. Addiction is about a compulsive craving for a drug for effects other than pain control. Dependency is about physiological adaption of the body to the effects of the drug, abrupt withdrawal will lead to withdrawal symptoms, but this doesn't mean the person is 'addicted' - they're not craving it to get a high, but simply to resolve symptoms.

Having said that, at the pain management centre I work at, we rarely use opioids because of their 'wind-up' effect. The 'analgesic ladder' approach is typically best practice to follow (simple analgesia, secondary analgesics, and finally, opioids). And we would add, nonpharmacologic approaches (cognitive behavioural approaches) should always be used first.

I've hesitated going to a pain specialist becuase of the fear of using too strong of meds.
Maybe I'll talk about it with my doc on friday. If the pain specialists here find other ways (and they work for lupus pain) I like that idea.

I'm terribly needle phobic ...yet I've found my pain is severe enough to allow even the AC shoulder joint injection ... frequently.

My ortho was so proud of me when I finally stopped fainting on him ...and even more proud at the last 3 injections that I continued to breathe all through the injection!

When i saw the title of this post, i thought it would be about IBS.

When I needed narcotic pain medications, I found it difficult to approach my doctor for fear of sounding like an addict (he turned me down the first time). I knew I truly needed it and luckily this doctor realized it too (I had to fight the urge to ask my PCP since this specialist had turned me down, again, I didn't want to look like an addict). Going to the pharmacy with that prescription always made me feel a bit ashamed inside.