Treating Chronic Pain Patients Is Rarely Easy

I recently saw a patient I haven't seen in a couple of years. She switched from my practice and now was back after her most recent primary-care doctor moved. She called in for a pain medication prescription for an acute injury. I groaned inwardly because I had been down this road with her before. Around the time she stopped coming to see me, she was fired by a pain clinic for using a friend's narcotics. So, instead of filling anything over the phone, I asked her to come in for re-evaluation.

Her exam revealed some minor abnormalities, but was limited by her pain. She was anxious and upset. She alluded multiple times to her previous problem with prescription drug abuse but reassured me that she could now be responsible. My first choice was a non-narcotic medication, to which she had an adverse reaction. Unfortunately, the patient was adamant that "weaker" opioids didn't work. Now, I feel torn between treating her pain and creating a problem all over again.

Increasingly, physicians are finding themselves caught in the pain management web. A decade or so ago, we were admonished to treat chronic pain vigilantly. That focus likely led to the increase in narcotic prescriptions written for chronic, non-cancer pain. Now, many years later, we are battling prescription drug abuse and the offshoots of heroin and other illicit drug abuse. In addition to being healers, we are asked to be policemen, making sure that our treatment is not being misused. While many of my patients use their prescription narcotics responsibly, many do not.

So, when I see a patient like the one described above, I am very torn. I want to do the right thing for the patient but feel caught between treating her acute pain - which is not measurable or objective - and saying "no" to something that has led to problems for her in the past. Often, patients will challenge me, like this patient did, to do something, as "nothing is working."

Pain is such a subjective experience and I believe it is real to some degree for the patients who come in reporting it. However, I recognize that many factors can influence how pain is experienced and how pain is managed. Furthermore, the medical community seems to swing from one extreme to another.

Recently, I had a patient come in who I have known for several years. Her cardiothoracic surgeon told her that he would not prescribe anymore narcotic analgesia following her open-heart surgery. She would either need to use Tylenol to treat the pain or be referred to a pain specialist. She was 10 days out from her surgery. While I appreciate the concern this surgeon showed for narcotic misuse, I also had to do a gut check and consider whether it might be reasonable for someone to continue to have severe pain just 10 days following surgery.

Unfortunately, I don't see a lot of answers on the horizon. While increasing attention is being paid to the challenges inherent in long-term prescription narcotic use, there are few options given for those patients who have uncontrolled pain. I have no clear answers, as evidenced by my patient. Instead, I try to balance reason with compassion.