To Treat or Not To Treat
One of the significant dilemmas physicians and prescribing practioners can find themselves in is dealing with the patient who claims to be in pain and who demonstrates significant drug-seeking/substance abuse behaviors. Whether you are a specialist or a general practitioner, you will at some point be faced with a patient that comes to your office requesting pain medications but clearly demonstrates behaviors that support a drug-seeker/substance abuser rather than a person who suffers pain and desperately seeks relief. Many practitioners may be asking how they should handle such a patient.
The fear of legal entanglement and the exhaustion of resources that can occur working with a patient population that is demanding and often unrealistic in expectations can be overwhelming. It is all too easy to become angry with these patients for their behavior as they appear to be goal directed and inflexible with the options you present to them. They want one thing and one thing only - drugs. To help with answering the question of how to handle these difficult patients, allow me to offer some suggestions to consider for your own practice.
It is important to understand that addicts are people who can also experience pain syndromes. Although they are unable to control their behavior, and although they can and do anger many practitioners because of the very way they misuse the system to feed and support their addiction, they still have a right to reasonable comfort. The problem is the fact the addiction really needs to be addressed before pain management can be effectively addressed and treated.
It is also important to understand there are a tremendous number of patients out there suffering because of those who have abused the system. As difficult as it is, we as practitioners need to be careful about erroneously labeling our patients. It is important for us to have a solid understanding of the many facets of pain and its management. Understanding what the differences are between tolerance, physical dependence and addiction are critical and vital in developing the ability to better identify abusers vs the patient, who is truly suffering and seeking relief.
I have presented some food for thought and ideas that I feel might help with the concerns and frustrations shared by practitioners related to this difficult patient population.
Related Topics: Back Pain: Medication and Addiction, Recognizing Addiction
Technorati Tags: painkillers, addiction, substanceabuse, chronicpain
The fear of legal entanglement and the exhaustion of resources that can occur working with a patient population that is demanding and often unrealistic in expectations can be overwhelming. It is all too easy to become angry with these patients for their behavior as they appear to be goal directed and inflexible with the options you present to them. They want one thing and one thing only - drugs. To help with answering the question of how to handle these difficult patients, allow me to offer some suggestions to consider for your own practice.
- Develop formal policies and guidelines for handling these patients before you need to use them. If you have a plan in place, you will be better equipped to address patients if and when a patient fitting this description appears at your office door. These may include developing or implementing a comprehensive questionnaire to be filled out at the first visit, information release forms to be filled out and signed by the patient. You may want to incorporate a rule that only information coming directly from a physician's office/clinic/hospital will be accepted as written history of diagnosis and treatment of the pain syndrome.
- Be straight forward with potential patients about the approach your practice takes in the evaluation and treatment of pain and pain syndromes. These folks can then determine if they can and will be able to support and accept the treatment approach presented. Anyone who is in genuine pain should appreciate this approach to diagnosis and treatment.
- Make it clear that new patients who are seeking pain relief should not expect to receive prescriptions for controlled substances until the physician/practitioner has the opportunity to review all past history and perform a comprehensive assessment of the patient's chief complaint. Then, if the practitioner feels that strong narcotics are warranted, they will be prescribed within strict guidelines in terms of dosage, frequency and duration. This may not be completed at the time of the first visit. Also clearly outline how a termination of treatment will be handled, i.e.: patient non-compliance, or determination of practitioner of the inability to appropriately and effectively treat the patient. Having a formal plan that requires a systematic review before treatment will help decrease the event of walk-ins seeking medication refills and multiple scripts for heavy narcotic or addictive medications.
- Treatment contracts that clearly state the expectations of the patient and require signatures at checkpoints during the treatment process may help to keep the patient accountable.
- Provide resources to assist the patient who demonstrates addictive behaviors. Names, addresses and telephone numbers of substance abuse clinics and rehabilitation centers and counseling services may help a patient seek help in these areas. Although you are not able to control what patient does with information and resources you provide, at least you can feel confident that you have not released a patient without providing them with something to help them as they seek proper treatment for their problems. Providing patients with the definitions and symptoms of addiction and drug withdrawal will help to realize your awareness of these situations and how to properly treat them. This way if someone who is truly seeking drugs related to addiction and abuse appears, he/she will know ahead of time they will not be treated with narcotic analgesics for pain or discomfort when they present with these symptoms.
- Be sure to document all objective behavior and statements made by patients that you use to diagnose and treat the patient. Describing the patient's complaints along with the behaviors they present will help to support the reasoning behind the decisions you need to make. You will want to have a clear understanding of what are considered acts of negligence and abandonment so you can be sure your practice is performed properly and guidelines and policies will protect you from any false claims by your patients.
- You might consider hiring or partnering with someone who specializes in psychology/substance abuse counseling and/or treatment. What better way to perform comprehensive assessments on patients in a timely manner than to have the ability to do so within your practice. And what better way to have a ready resource for handling and assisting in the treatment of those patients who present with a significant addiction problem overshadowing any possible pain syndrome.
It is important to understand that addicts are people who can also experience pain syndromes. Although they are unable to control their behavior, and although they can and do anger many practitioners because of the very way they misuse the system to feed and support their addiction, they still have a right to reasonable comfort. The problem is the fact the addiction really needs to be addressed before pain management can be effectively addressed and treated.
It is also important to understand there are a tremendous number of patients out there suffering because of those who have abused the system. As difficult as it is, we as practitioners need to be careful about erroneously labeling our patients. It is important for us to have a solid understanding of the many facets of pain and its management. Understanding what the differences are between tolerance, physical dependence and addiction are critical and vital in developing the ability to better identify abusers vs the patient, who is truly suffering and seeking relief.
I have presented some food for thought and ideas that I feel might help with the concerns and frustrations shared by practitioners related to this difficult patient population.
Related Topics: Back Pain: Medication and Addiction, Recognizing Addiction
Technorati Tags: painkillers, addiction, substanceabuse, chronicpain
12 Comments:
Thank You So Much Indie! I'm a chronic pain patient and have been being treated as such for a least 6 years now. The first doc I had diagnose and treat me was a general practitioner and, now from experience, I can say she really didn't know what she was doing in treating my chronic pain. It made it very difficult on both of us since I didn't know how to control my dosages either! I ended up going through 3 weeks of severe withdrawals and coming very close to attempting suicide, mainly because I didn't know where to go for help and the aforementioned doc didn't tell me where to go nor would she take my phone calls any more. Needless to say I think we both learned some very important lessons from that. This is some of the best information I've seen available to both doctors and patients. I'm actually going to print this and keep a copy handy. Although the rheumatologist I'm seeing now has a pretty good handle on this type of thing, more (acurate!) info wouldn't hurt! Thanks Again!
Your article makes several very good points, especially about the contract. I am seeing an MD for my pain control right now but he is well versed in chronic pain and what a person has to deal with as well as how for him to best work with the patient. He did agree to prescribe a painkiller for me on my first visit but he looked at my chart and listened to what I had to tell him, and it was not hard to tell I was in extreme pain at the time as I was almost in tears I was in so much pain. The first thing he said was that he would agree to help with the pain meds but only and I specify only if I agreed to sign a contract with him that I would only come to him and not Dr. shop, whwich I had absolutely no problem with at all. I think part of the problemis that some Dr.s will see a person but then not make any attempt to get back in contact with them or by taking a long delay period to look at their chart before making any kind of decision, and that is where the patient that truly needs the meds is being mistreated. Unfortunately I think there are some Dr.s out there that just try to get as many patients as possible so that they look good to others but they fail to take into account the fact that just rushing through patients does nothing for the patient at all but make them mad. I hope you will pass along the posts you receive in response to the medical professionals around you some of them I'm sure could learn something from both your article and the responses you receive.
indie, thank you for your article. i've had c-spine problems since 1972. i never needed or took a lot of pain meds until 6 weeks after my 1st c spine surgery in 02. i did not know what dr shopping was in 02 but i learned. i stayed with the same doc for this 3 1/2 years, i told him about every specialist i went to because each doc wrote him a letter. i didn't hide anything. accupuncture was the only other doc i asked to give me pain meds but he said no, so i never asked another doc again. i still could not get them until 7 months after my 2nd surgery (08/04) and a car accident and my husband being a little firm with the doc. after going to the same doc for this long they don't believe you. a neuro told me i had psyco problems. my husband asked him if he was qualified to make this diagnosis but he didn't answer. this was the begining of fighting back when docs treat you bad. when i first saw a new doc,i wasn't looking for pain meds.i wanted a diagnosis and this was made known to them. one neuro i went to sent me for an MRI. he then sent me a leter stating there was nothing wrong with me and if i wanted to discuss it i could make an appt. the appt i got was 3+ months later so i let it go. this is rude. my ins co paid him alot of money for an initial visit and i could not ask any questions. i understand better now that doctors do have a tough time sorting legit pain patients but 50% are mean and they don't have to treat you bad. if they would just listen instead of judging. if they would explain things and how they work people wouldn't have to seek help elsewhere. i divorced my family doc 2 weeks ago with a 7 page letter leting him know how i felt about the things he did. i felt bad for a couple days but then the relief became greater. i finally found a doc that gave me a diagnosis after seeing about 20+ docs and 1/2 of them telling me nothing is wrong.
I have had chronic pain for over 30 years and have tried every know remedy on the planet. I am also a broadcaster which requires plenty of traveling. About 50%, yet not excessive to my condition which is from severe back pain. I had 3 spinal fusions to attempt to help reduce the pain I have. The 3rd surgery was a success in 2003 but now I am beginning to have a new problem.
Since I have moved often or have had to change docs over the years your comments for doctors is absurb and potentially detrimental to people like me. You are one of those people (and there are a few of you) that have been tainted by drug addicts doctor shopping. Your approach would only cause even more suffering to millions already emotionally scared from the medical community. Here is a common sanario for you. I have been going to a PAIN MANAGEMENT doctor for years now. Just a week ago I had to go to the ER due to an increased amount of pain in my hip. I have been prescribed methadone for my chronic condition, well the doctor in the ER thought it amusing to ridicule me for being on a medication that is used for Heroin addicts. Obviously he was not aware of pain management.
My remedy to the entire problem: When doctors go to medical school, teach them pain management. Currently I understand they get all but a day of education on the subject.
cheers
tiredandinpain
Very well written article. I feel that this is idel for every pain clinic. Thank you.
itmay be good for doctors who admit they don't know it all.....I believe many of us are treated in a way which is contrary to our best quality of care largely due to patients who are drug seeking......I have worked with these individuals and they are scam artists...the article did nothing for me personally however
In general, I think your approach is well-taken. I've only been a chronic pain patient for three years, but have found that information sharing among *all* who treat you and absolute honesty about how you use drugs is critical to getting treatment. Don't omit anything when you talk to a doc about your meds: how often, how much, and how well they work (or not).
I wonder if doctors realize how afraid some of us patients are of becoming addicted. I found that sharing these fears of mine helped both my doctor and myself to initiate discussion on this subject. Both of us got needed reassurance in this very murky area.
I'm still concerned though, since I have a cross-country move coming in a few months. But I hope and plan to get copies of all of my records to take to a doctor and/or pain specialist in my new location.
If you lay your cards on the table, most docs will at least look at you with some modicum of respect.
Mary Rose
So this is our "expert" opinion with some guru advice. I, so, agree with previous comments about how people in the medical field ought to take classes on pain management. My husband has been a chronic pain sufferer for 17 years and it's people like this who really ought to sit in front of a computer all day instead of deal with people.
i was accused of drug seeking at my first vist to a new doctor in a new town. I felt he jumped on it as it was my first vist .I had records that I guess he didnt look at. I have 10 bad discs in my back. Two in my neck, 3 in the middle and all 5 in my lumbar with no surgery. I do know that he jumped the gun. When I found out I never returned.
Here we go again...I have been in pain for 10 years, every day, and doctors with opinions like yours, are the reason why. (Still no diagnosis, but possibly fibromyalgia.) I have done everything asked of me by the myriad of doctors I have seen, including injections in my neck that actually made the pain WORSE, and I still cannot get the meds that I know help me. Am I a drug seeker? Heck yes, I am! I seek medication to help relieve my constant pain!! What is wrong with that??? So some teenager stole Mom's pain meds, did some crack, and died. Is that my fault?? Or the doctor's? NO!! It was the kid's fault.
I manage to work full-time while eating aspirin and ibuprofen, destroying my stomach. Docs are willing to pass out SSRI's like candy, but they are highly addictive! Anyone who says otherwise is lying. I was put on Zoloft for my "pain," but all it did was make me more anxious & angry. When I tried to wean off of it, I had horrible withdrawals, so I had to continue. I can get refills on those anytime I want. But is that okay???
I seek meds to get relief so I can be a productive woman, a good wife, and a good daughter. What in God's name is bad about that?? I thought in America people are innocent until proven guilty. I know people who do illegal drugs, and NONE of them go to pain docs. They STEAL them, either from pharmacies or corrupt drug reps. This has become an epidemic. People are resorting to suicide for pain relief - how does that fit in with your Hippocratic Oath, huh? Quit being afraid of the loonies at the DEA - if you don't want to treat people for pain, don't be a pain doctor then.
This article is just another reason I'm sitting here in agony right now, trying to get the nerve to off myself. Thanks for nothing.
Excellent article. Those of us who are NOT drug-seeking have no fear of any of your policies. I'm on a contract myself and wouldn't think about breaking it. I recognize that it's BECAUSE of the drug seekers that contracts are needed, so if anyone out there is angry, let it be towards those who make our lives miserable. Are far as this article goes, the author expresses legitimate problems our physicians face daily!
The article addresses how to manage drug seeking patients but does not address what patients should do to address doctors who fail to provide proper pain management. I'm on my fourth pain doctor. The first, only gave injections! The second, only gave injections???? (I thought they said they were PAIN MANAGERS"). My family doctor didn't believe I couldn't find a doctor to manage my "pain meds" claiming he never heard of pain docs only giving injections. My third doc managed my meds but reduced the narcotic by half on the first visit, and would NOT increase them even after two ER visists were approved by him. The fourth doc has a comprehensive service, does narcotic mgt, has injection doc available, a headache clinic etc. She immediately increased my narcotic meds, gave me nerve pain meds, and after 2 visits set me up for injections. We have a PLAN OF ACTION. Now we're getting somewhere. My POINT - Don't give up. Keep looking - You are ENTITLED to pain relief. Join a pain organization so you can get information to be empowered, feel more in control. Definitely get to a pain psychologist and if you can't afford, find a pain support group. Just keep moving yourself towards finding relief. It is OUT THERE!
my pain management doc likes to tell me "I'm not going to court again." This comment while reading over records sent to him from my internist whom has been treating my pain for over 4-years with opiods (lortab/fentanyl) & now a recent increase in hip pain. I replied, "I don't want you to have to go to court again either!"
We're damned if we do, damned if we don't.
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