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Prescribing painkillers can land docs in hot water

April 29, 2007 12:36 am

MOST patients take medicines only grudgingly if at all. Even if it's something absolutely essential, like diabetes medicine or blood pressure pills, they will let themselves run out and give us fits for fear they'll have a heart attack or stroke.

But there is one subset of patients who are just the opposite. They turn up in the front office and make a scene. They call every hour. They falsify scripts and generally act thoroughly nasty if they are even close to running out of their medicines.

These are people on benzodiazepine tranquilizers and pain medicines, and they cause my colleagues and me a lot of anguish.

Benzodiazepines are technically tranquilizers, but that makes one think of elephant guns and veterinarians. The politically correct term is "anxiolytics," meaning they treat anxiety.

Valium was the first of these drugs to hit the market in the 1950s and was hailed as a wonder drug. It gained a huge market as "mother's little helper" before doctors realized it caused a nasty dependency and vicious withdrawal syndrome when you try to get off it, with a rebound of anxiety. Other modern meds in the same class are Xanax, Ativan and Klonipin.

The sages of our profession nowadays recommend weaning people off the drugs. But tell that to some highly strung old lady who's been on Xanax three times a day for 15 years and is thoroughly dependent. See how popular it makes you.

Painkillers are the other big class of medicines that cause dependency. Virtually all of the major painkillers (including the different types of codeine) are derivatives of the parent compound, morphine, itself a derivative of opium--which of course comes from those pretty poppies the Afghans are so fond of growing.

Most infamous among these are Percocet, Oxycontin and Vicodin (made famous as the drug of choice of TV's Dr. House). The list is very long.

In my practice and those of many other providers, there are multiple patients with painful conditions such as back pain, arthritis and fibromyalgia who consume massive quantities of pain pills. It makes me uncomfortable.

Many of them have legitimate needs. But many of them, I feel, are dependent-type people with quasi-psychiatric conditions. It is my impression that they are using pain medicine as a psychological prop as much as to keep the pain at bay. Yes, they have pain. But they have no interest in trying other treatments. They are happy to suck down vast quantities of narcotics. It has become a way of life.

Another worry is that patients are using the pills to get high--a notion reinforced by the number of people who suddenly find they've run out of their pain medicines or their tranquilizers on a Friday afternoon. I worry they just want them to party over the weekend.

Even more concerning is diversion. These narcotics have a high street value--Oxycontin goes for about $100 a pill, I am told. So, when you leave the doctor's office with a month's supply of 60 Oxycontin, and you're on the skids and living on disability--and many of these people have lost their jobs due to their medical conditions--I can't help thinking there must be a hell of a temptation to indulge in a little "diversion," as the selling of prescription medicines is so cutely called.

Maybe I'm being uncharitable and am tarring all pain patients with the same cynical brush. But maybe it's just that the general public is a little naive and doesn't appreciate the problems associated with these drugs. (It calls to mind the early days of cocaine, when the drug was an ingredient in Coca-Cola before anyone realized the addicting nature of it!)

The pain medicines that are essential to some become an unhealthy way of life for others, while yet others--the so-called "hitters"--just fake the pain and con the doctors. There's no objective test to measure pain.

Many doctors just flat out refuse to prescribe pain medicines--even though the experts and the literature tell us that pain is under-treated, and many, like myself, think treating people's pain is an obligatory part of practice.

Very commonly, those of us who are willing to prescribe narcotics have patients sign an agreement:

They will be given medicines only at office visits, not over the phone, which often means being seen every month.

They are not allowed to take more medicine than it says on the prescription.

They will get their narcotics from only one doctor.

Sometimes, the patients balk at these persnickety regulations, but it is our protection against following in the footsteps of the likes of Dr. Frank Fisher (see sidebar).

It is a fraught business knowing what to do. Should one just go on doling out the medicines, or should one take on the good fight and try to wean these patients?

Normally, when you're not sure how to treat a patient, you refer them on to the relevant specialist. But, at the risk of being controversial, the breakup of Psychiatric Associates and the fact that many local psychiatrists have left town or gone out of practice means it is difficult to get patients seen. Not to mention that when you suggest such an idea, the patient looks at you as if you are the one who's crazy.

Pain management services are not much better. They're usually provided by anesthesiologists, rheumatologists or physiatrists (physical medicine doctors), who are focused on giving shots and procedural cures when what one really needs is a blend of pharmacist/psychiatrist/social worker/priest.

Practicing medicine has its rewards, but it has its stresses, too. The conflict of "Is it OK to go on prescribing addictive medicines?" is one of the knottier issues. So when you come to get your Percocet or your Xanax refilled and I look at you cross-eyed, you'll know why.

Dr. Patrick Neustatter can be reached at pneustatter@prattmed .com.