Difficult choice with prescription narcotics

On the list of issues more painful for doctors than hammering their own thumbs is the prescribing of narcotic pain medications. Doctors are increasingly caught between the rock of law enforcement efforts to stamp out illegal narcotic pill use and the hard reality that many patients need more pain medication, not less.

Neither the rock nor the hard place is anything doctors can ignore. State and federal drug laws are a presence doctors can feel breathing down their necks in the office, and careless prescribing of narcotics can cost a doctor the ability to practice medicine. On the other hand, agencies such as the Joint Commission on Accreditation of Hospitals, and the public, are appropriately hammering American doctors and hospitals to treat pain more aggressively, which will require more narcotic use.

Despite the best efforts of the American pharmaceutical industry, narcotics remain the best pain relievers available. Other medications and therapies may work in some patients, and may be useful as additional therapy in others, but some patients simply must have narcotics to control their pain.

What makes prescribing narcotics difficult for doctors is chronic pain, because that is the nearly universal complaint of patients seeking narcotics for an addiction. Chronic pain is the medical equivalent of fog; nebulous, subjective and intangible, and there is no test for its severity. Excruciating back pain can exist in a patient with a normal back X-ray. The subjective nature of pain means that some patients need narcotics for their pain, some need it for their addiction, and the difference between such patients is often indistinguishable.

A typical chronic pain patient can be a doctor’s nightmare. The patient’s back has been operated on several times in attempts to relieve his back pain, and looks on X-ray like a bulldozer has been used instead of a scalpel. He walks like a two by four with legs. Without narcotic pills, he says, he might as well be dead because the pain makes life unbearable. He only has a reasonable quality of life if he takes his pain medications. Attempts to wean him from narcotics always fail.

The truth is that such a patient could be using his pills legitimately; most chronic pain patients are, and suffer daily from the kind of pain that would bring most of us to our knees. He could also be abusing his narcotics, or could be selling them on the street. In such cases a reasonably careful physician has no way to be certain whether he is being a compassionate doctor or a dupe. Patients abusing prescription narcotics are rarely obvious. They usually look and act like the rest of us, they don’t have green hair, and they never just walk in and say, “Doc, I am addicted to narcotics and would like you to give me 500 Oxycontins.”

Regardless of the confusion, adequate pain control for some patients means narcotics, and the appropriate availability of narcotics for some means inappropriate availability and abuse by others. This is the dilemma for our society. The price of adequate pain control is some abuse of prescription narcotics. The dilemma is illustrated by the prescription narcotic Oxycontin; the reason it is so widely abused is that Oxycontin is widely available, and the primary reason it is so widely available is that Oxycontin is a great pain reliever.

While physicians can and should be expected to prescribe carefully, they cannot be expected to prescribe without error. If every patient with real pain gets the relief they need, some addict claiming pain is going to get narcotics for their own use and for sale. The only way to reduce the errors to zero is to reduce the prescribing of narcotics to zero.

Efforts to fight prescription narcotic abuse by changing physician prescription practices are legitimate, but every effort to control narcotics that way must be measured against the accompanying cost in uncontrolled pain. Doctors are generally a paranoid group desperate to avoid legal entanglement and the chance they will hook their patients on narcotic pain pills. If they are nervous about prescribing narcotics they will prescribe fewer narcotics. That may leave a few pill addicts without Oxycontin, but it will also leave a larger number of legitimate patients without adequate pain control.

Had physician-assisted suicide been legalized by November’s referendum on the subject, the cost of uncontrolled pain for some terminally ill patients would have been their deaths by suicide. Instead, uncontrolled pain will continue to mean unnecessary suffering for such patients.

We cannot have complete control of narcotics and complete control of our pain. To some extent, we will have to choose which is more important, a difficult choice for a society in which more and more of us are getting to the age where pain is a bad part of every day.

Erik Steele, D.O. is the administrator for emergency services at Eastern Maine Medical Center and is on the staff for emergency department coverage at six hospitals in the Bangor Daily News coverage area.