Monday, July 2, 2012

The Doctors' Dilemma

   Last week I wrote about an epidemic of opiate pain killer addiction, and the nearly 40,000 accidental overdose deaths this led to last year. Two glaring concerns follow from this statistic. When a physician raises his pen to prescribe one of this class of drugs - be it oxycodone, vicodin, morphjine, or percocett - there is no way he or she can know ahead whether the person on the other side of the desk will become another of this growing number of addicts, a transformation that can happen in as few as three days of first use. Unwittingly the physician may be writing a death warrant. Investigators at Stanford University School of Medicine led by Dr. Martin Angst find that whether we will get addicted to opiate drugs, what dose we need for adequate pain relief and what kind of side effects we experience, be euphoria, nausea, sleepiness, dizziness, blurry thinking or none at all, is wired into our genes. While the idea of being able to test for these factors before prescribing is attractive; the worrying detail here is that the patient who has both high propensity for addiction and high dosage requirements for pain relief, and little to no unpleasant side effects, probably should not given an opiate unless already dying with a painful disease .

The truism that 80 percent of all American adults will have back pain at some time in life is born out in my office, where I treat a variety of pain sources, often from sports injuries, but equally from back or neck injuries. A number of doctors like myself in the past year or so have seen a sharp uptick in patients searching for a new doctor because the previous one no longer wants to fill the demand for opiate prescriptions. I have come to recognize the telephone call. The patient has been given opiates in one form or another for sometimes longer than ten years.  The original pain is now hard to identify and the old doctor now either feels inadequate to manage addiction or fears being cited for wrongful prescription writing. These patients fall at one or the other end of the spectrum: They have learned to mimic pain, know all the right answers to the doctor's questions and even stand and sit as though in pain, but have a normal examination; or they have come to believe there is something wrong with their nerves or skeleton that cannot be restored to pain-free normal and are resigned to a life of opiate dependence. Some in each group will already be addicted. Members of the first group I see for only as long as it takes to see their game; the opiates obtained from the doctor will be consumed by the patient or sold on the street. The second group gets my attention. Why have they fallen into this opium trap?

The sorry answer lies somewhere between the practice of medicine and its regulators; the insurance groups. Increasingly in response to steep reductions in insurance payments (known politely as "benefits") doctors are being forced either to increase volume, which is to say curtail time with each patient, or in many cases, go out of practice. Opening an envelope containing less than sixty dollars for a hour with a patient in pain can be unnerving! When I spoke with the medical director for one insurance provider about this problem he said, "you live in an antiquated world, Dr. Duncan. We pay for 15 minute office visits; patients no longer require an hour." I wonder whether he has read of Columbia University's new department, Narrative Medicine, led by Dr. Rita Charon, who like myself, has discovered that if we do not listen we cannot learn what is wrong with our patients, nor can the patients feel that we care; an important ingredient in being willing to put down opiates and do what it takes to get well.