Why your family doctor may be afraid to treat your pain.
All family doctors used to treat pain. It was considered normal standard of care. When I started
practicing medicine fifteen to twenty percent of a primary care doctor’s patients would have intractable
pain and would be on pain medications. About fifteen years ago doctors were told that we were not
treating pain adequately. Studies showed that most people with severe pain could manage their
medications appropriately and that the increase in quality of life outweighed the risk of addiction which
is about 4 to 6% of patients started on opiate pain medications. Doctors were graded by whether
patients reported their pain as sufficiently controlled. If a patient passed away the coroner would look
for a cause and list that cause on the death certificate.
Then fentanyl came on the scene. It is hard to smuggle a desk sized block of heroin into the US
without getting caught. It is a lot easier to smuggle a vial of fentanyl. Fentanyl is about 50 times
stronger than heroin. Now carfentanyl has been approved and it is 100 times stronger than fentanyl
which makes it 10,000 times stronger than morphine. These drugs would be smuggled in and used to
make fake heroin, and even fake hydrocodone and fake oxycodone in someone’s basement with a pill
press. People started dropping dead at an alarming rate. This was declared to be an opioid crisis and
the pharmaceutical companies, politicians and federal law enforcement looked for someone to blame.
The companies did not fault their production of highly potent medications, they blamed the patients.
The politicians didn’t fault their approach to the “drug war”, they faulted the doctors. The federal law
enforcement agencies and medical boards don’t choose these laws. They enforce them and are subject
to political pressure. New rules and restrictions were issued.
Family doctors became worried that they could not keep up with all the rules and started opting out
of pain treatment referring their patients to doctors who continued to treat. Those still treating pain
had to dedicate staff and hours to making sure that every regulation was followed on every patient. We
took extra courses on pain management and opiate addiction. Some of us became certified to treat
addiction and started helping in addiction clinics. But as the criticism worsened there were not enough
doctors still treating to handle the number of patients that needed to be continued on pain
management or safely brought down off the medications. Doctors still treating pain would have more
patients walk through their door begging for help. Pain specialists became swamped with patients who
had already been through all the surgeries and interventions possible and just needed medical pain
management. The number of opiate prescriptions in Arkansas started dropping.
The number of patients seeking addiction treatment began to sky-rocket when patients abruptly
taken off their medications went to the street to buy them and found out that real hydrocodone is
extremely expensive but fake heroin is cheap. Then the opioid crisis became an opioid panic. The
politicians decided things weren’t moving fast enough and mandated that examples be made. Doctors
started to be charged with murder if a patient died while on controlled medications. Any patient who
died on while taking pain medications was listed as “possible opiate related death”. More patients were
abruptly dropped from their medications. More patients seeking relief ended up on the street. Then
patients whose medications had been reduced below a tolerable level started committing suicide.
Amazingly these patients are listed in the database as “possible overdose” even if they died from a
gunshot wound to the head. If a doctor must fire a patient for misuse all that patient has to do is write a
letter to their insurance company or the medical board and that doctor will almost certainly be shut
down while their records are reviewed.
Even if, after months, it is found they were practicing good medicine the shutdown leaves hundreds
of desperate patients going to overworked emergency rooms to be turned away. I have seen patients
with bone cancer turned away from the emergency rooms and told “It’s not our fault your doctor got
you addicted to pain medicine.” Some of these patients will go to the streets or kill themselves.
The new Prescription Monitoring Program, created to reduce diversion, was turned on the doctors.
The number of patients you see, the distance they drive, the strength of their medications, could all be
put into an algorithm and a list of doctors could be generated. These doctors would then be targeted,
charts would be non-randomly reviewed, pharmacists would search for outliers, then the doctor would
be called in to explain this “unreasonable prescribing”. The Arkansas Intractable Pain Act of 2006 could
be ignored as there is no one to enforce it. I don’t know where this will all end but I do know it is only
going to get worse from here. Doctors must, of necessity, now practice defensive medicine. They must
choose between treating those who suffer and possibly losing everything it took over twenty years of
education to achieve. Your family doctor has a reason to be afraid to treat your pain. If you follow the
link below you will find that even the physicians on the state pain board are terrified. I don’t know all
the answers to these problems but perhaps thoroughly review a doctor’s actions before shutting down
their practice. If they are following the published rules give advice but don’t destroy their reputation.
Start a medically assisted treatment program while addicts are incarcerated, the success rate is over
80% compared to without medication which is about 17%.
Addiction treatment has a higher success rate than the treatment of high blood pressure or diabetes.
I have written Senator Cotton about this twice but have yet to receive a response. If you are on pain
medications understand that your doctor may have no choice but to reduce or stop them. This is not a
reflection of your legitimate need but an acknowledgement of the dangers to the doctor personally. If
you have been abruptly taken off your medications and you cannot resist the urge to try to find them
from another source seek help at an addiction clinic. Do not go to the street to try to replace your
medications. You can die. And do not kill yourself. You can get help through this difficult time; better
treatments will be found if you can hang on long enough. Your suffering will not always be this severe.
There is hope, do not give up.
L. Joseph Parker MD, MSc Capt. USAF (Ret)