Does Your Health Care Provider Treat Pain?
Over at Kevin, M.D.'s Medical Weblog there is discussion of the choice of some physicians not to apply for a Federal Drug Enforcement Agency (DEA) licenses to prescribe Schedule 2 drugs (potentially addictive drugs with critical medical use, such as opiate-based pain medications). One case that he describes is that of a patient who becomes very ill and requires pain medication (see Thursday, 1/6/06 blog). The patient goes to his primary care doctor only to find that he does not have a DEA license to prescribe narcotics. The patient was forced to find a new provider to manage his cancer pain while he was in the crisis of illness.
This weblog discussion is based on a current article in the New England Journal of Medicine (NEJM) regarding the potential for the DEA to become involved in examining physician's practices for writing pain medications for individuals at the end of life. This article points out, "Although a lack of proper training and overblown fears of addiction contribute to such undertreatment, physicians' fears of regulatory oversight and disciplinary action remain a central stumbling block" for prescribing Schedule 2 drugs. Well, I'm not buying that; I think for many providers the overblown fear of regulatory oversight is an excuse not to do the hard work of pain management.
I find the choice of any provider not to prescribe appropriate pain medications unthinkable, and their excuses for not doing a portion of the job that is critical to patient's comfort morally reprehensible. If, as the NEJM article points out, the individual provider feels inadequately trained to provide pain management, then seek out the education needed. This is important to patients: poorly controlled or uncontrolled pain and other distressing symptoms are the greatest fears of patients facing serious illness. According to research, greater than 90 percent of the pain associated with severe illness can be relieved if providers adhere to well-established guidelines and seek help from experts in pain management or palliative care as needed.
I have been in a physician-NP practice for 2 years; like any practice, we have our share of folks looking for narcotics to take away the pain of life for a bit. In my opinion, if a provider is thoughtful and consistent in their practice, a chart audit will indicate that there is no reason to suspect their prescribing practices. There are specific steps that can be taken by a provider to protect themselves from both DEA criticism and the drug-seeking patient.
For example, each pain management patient should be seen on a regular basis (for me it's quarterly at a minimum or their prescriptions aren't refilled) to evaluate and document their pain and level of functioning on their current regimen. If it's appropriate all of my pain management patients are also going to physical therapy or to pain management specialists for other modalities, such as steroid injections. Ongoing participation in these consults is a requirement for them getting pain medications renewed.
It is also important to create certain expectations with the individual patient to keep a provider from being marked as a pushover when it comes to obtaining a narcotic prescription. For example starting off with the stated anticipation that a certain acute injury will need roughly "x" amount of healing time, that the provider expects a prescription to last the person at least a certain number of days and wants to hear from them earlier if the medication isn't "holding them," (rather than calling 4 days early because they're all out of pills), and stating an expectation that they will have started PT by their next visit are all possible appropriate options. These statements set the individual up knowing that the provider sees a time limit to the need for narcotics and that you are working together to get them well and back to full functioning. This scenario of course presumes that the injury is capable of healing; certainly the discussion is different when an individual is terminally ill.
In two years we've built a busy practice and I can count on one hand the few people who've really been a problem. Those individuals sign a pain agreement, which requires them to use a single pharmacy and get all their narcotic prescriptions from our office. It takes very little time to weed those problem individuals out after that, because a call to the pharmacy board got me a report on all their filled prescriptions since our agreement was signed. Those individuals were then told that our office would continue to manage all of their medical problems and that we would refer them to a pain management specialist for this particular issue. We also offered referral to help for their addiction, if the over use problem was theirs.
Do these practices potentially foist the narcotic abuser off on someone else? Yes. But doing them and documenting them in the patient's chart also keeps an individual providers butt out of a sling if a chart audit occurs. More importantly to our patients it also allows providers to safely offer a critical service to individuals in pain.
No one ever told me practicing medicine would be easy; in fact it isn't easy. The decisions that health care providers make every day can mean life or death, comfort or pain. The decision to prescribe narcotics safely and effectively is as important as any other treatment decision I make, and I believe that my patients with pain deserve to have access to this care from the provider who knows them best. I didn't start out with the knowledge to prescribe narcotics in this manner, but I sought the needed education that is available to any provider who chooses to avail themselves of it. So the next time you are seeing your health care practitioner, ask if they prescribe narcotics when they are necessary. You don't want to find out they don't when you're in pain.
Laurie
Related Topics: Care at the End of Life, Cancer Pain
This weblog discussion is based on a current article in the New England Journal of Medicine (NEJM) regarding the potential for the DEA to become involved in examining physician's practices for writing pain medications for individuals at the end of life. This article points out, "Although a lack of proper training and overblown fears of addiction contribute to such undertreatment, physicians' fears of regulatory oversight and disciplinary action remain a central stumbling block" for prescribing Schedule 2 drugs. Well, I'm not buying that; I think for many providers the overblown fear of regulatory oversight is an excuse not to do the hard work of pain management.
I find the choice of any provider not to prescribe appropriate pain medications unthinkable, and their excuses for not doing a portion of the job that is critical to patient's comfort morally reprehensible. If, as the NEJM article points out, the individual provider feels inadequately trained to provide pain management, then seek out the education needed. This is important to patients: poorly controlled or uncontrolled pain and other distressing symptoms are the greatest fears of patients facing serious illness. According to research, greater than 90 percent of the pain associated with severe illness can be relieved if providers adhere to well-established guidelines and seek help from experts in pain management or palliative care as needed.
I have been in a physician-NP practice for 2 years; like any practice, we have our share of folks looking for narcotics to take away the pain of life for a bit. In my opinion, if a provider is thoughtful and consistent in their practice, a chart audit will indicate that there is no reason to suspect their prescribing practices. There are specific steps that can be taken by a provider to protect themselves from both DEA criticism and the drug-seeking patient.
For example, each pain management patient should be seen on a regular basis (for me it's quarterly at a minimum or their prescriptions aren't refilled) to evaluate and document their pain and level of functioning on their current regimen. If it's appropriate all of my pain management patients are also going to physical therapy or to pain management specialists for other modalities, such as steroid injections. Ongoing participation in these consults is a requirement for them getting pain medications renewed.
It is also important to create certain expectations with the individual patient to keep a provider from being marked as a pushover when it comes to obtaining a narcotic prescription. For example starting off with the stated anticipation that a certain acute injury will need roughly "x" amount of healing time, that the provider expects a prescription to last the person at least a certain number of days and wants to hear from them earlier if the medication isn't "holding them," (rather than calling 4 days early because they're all out of pills), and stating an expectation that they will have started PT by their next visit are all possible appropriate options. These statements set the individual up knowing that the provider sees a time limit to the need for narcotics and that you are working together to get them well and back to full functioning. This scenario of course presumes that the injury is capable of healing; certainly the discussion is different when an individual is terminally ill.
In two years we've built a busy practice and I can count on one hand the few people who've really been a problem. Those individuals sign a pain agreement, which requires them to use a single pharmacy and get all their narcotic prescriptions from our office. It takes very little time to weed those problem individuals out after that, because a call to the pharmacy board got me a report on all their filled prescriptions since our agreement was signed. Those individuals were then told that our office would continue to manage all of their medical problems and that we would refer them to a pain management specialist for this particular issue. We also offered referral to help for their addiction, if the over use problem was theirs.
Do these practices potentially foist the narcotic abuser off on someone else? Yes. But doing them and documenting them in the patient's chart also keeps an individual providers butt out of a sling if a chart audit occurs. More importantly to our patients it also allows providers to safely offer a critical service to individuals in pain.
No one ever told me practicing medicine would be easy; in fact it isn't easy. The decisions that health care providers make every day can mean life or death, comfort or pain. The decision to prescribe narcotics safely and effectively is as important as any other treatment decision I make, and I believe that my patients with pain deserve to have access to this care from the provider who knows them best. I didn't start out with the knowledge to prescribe narcotics in this manner, but I sought the needed education that is available to any provider who chooses to avail themselves of it. So the next time you are seeing your health care practitioner, ask if they prescribe narcotics when they are necessary. You don't want to find out they don't when you're in pain.
Laurie
The desire to take medicine is perhaps the greatest feature which distinguishes man from animals.
Sir William Osler (1849 - 1919) British (Canadian-born) physician
Related Topics: Care at the End of Life, Cancer Pain
Tags:
2 Comments:
i work at an office with new drs who, unlike the prev physicians, wont give out narcs. it sticks the patients in a situation where they arnt being weened off of them. i dont think this is fair to the patients or the staff to have to deal with theses patients who are suffering because lack of caring and lack of correct treatment. its scary and i think isnt good practice.
I THINK THAT THE PROBLEM TODAY IS THAT MOST DR.TODAY IS MORE CONCERNED WITH THE AMOUNT OF MONEY THAT THEY ARE GOING TO MAKE INSTEAD OF THE QUALITY OF LIFE THAT THEIR PATIENTS ARE EXPERIANCEING.IF THE DOCTORS WOULD TREAT THEIR PATIENTS WITH THE NUMBER ONE RULE: TREAT EVERY PATIENT AS IF THEY WERE YOUR MOTHER THEN YOU WOULDNT HAVE HALF THE PROBLEMS WITH THE WAY PEOPLE ARE BEING TREATED TODAY.MOST DOCTORS HAVE THE ATTITUDE OF TREAT THEM AND STREET THEM.PAIN IS REAL.I CAN ATTEST TO THAT.I HAVE LUPUS WHICH LEAVES ME IN SUFFERING,AGGONIZING,THE WORST PAIN IMAGINABLE.BECAUSE OF THE LUPUS I SUFFER FROM MIGRAINES,PANCREATITIS, BAD CASE OF BLOOD CLOTTING ISSUES.I HAVE CYSTSIN MY UTERUS ,ALONG WITH ALOT MORE PROBLEMS.MY OB/GYN REFUSES TO GIVE ME A HYSTERECTOMY BECAUSE SHE THINKS I AM TOO YOUNG.I HAVE HAD MY TWO KIDS I AM READY.BELEIVE ME BEYOND READY.I GET NO PAIN MEDICINE FOR THAT AGGONIZING PAIN.SHE SAYS DEAL WITH IT.HOW ABOUT TREATING ME LIKE A PERSON?NO INSTEAD I GET TREATED LIKE A MONEY PIT.SO I QUIT GOING AND HAVENT HAD A PAP DONE IN OVER FIVE YEARS.WHAT IS THE USE.THEY ARE JUST MILKING ME FOR MONEY.MAYBE DOCTORS SHOULD TREAT PEOPLE LIKE THEY HAVE FEELINGS AND ARE ENTITLED TO THE SAME QUALITY OF LIFE AS THEIR FAMILIES.(THE DOCTORS FAMILIES).DOCTORS HAVE BECOME TO BE A MONEY RAQUET NOT CARING ,COMPASSIONATE HUMAN BEINGS LIKE THEY SHOULD.SOMTIMES NARCOTICS ARE THE ONLY THING THAT WORKS AS FAR AS QUALITY OF LIFE GOES OR IS IT THAT CELEBRITIES AND DOCTORS AND THEIR FAMILIES ARE THE ONLY ONES THAT DESERVE A DECENT TO GOOD QUALITY OF LIFE.
Post a Comment