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Holding a Pharmacist Hostage - The Unforeseen Perils of Provider Empathy
Healthy Living - September 30, 2014
William Sturrock, MD
Thirty years ago physicians did not readily provide prescriptions for narcotic pain relievers. These medicines were felt to be dangerous and carried a significant risk of addiction. Their usage was generally saved for severe but temporary medical problems such as heart attacks or kidney stones, or allowed as compassionate use for dying patients. Several developments toward the end of the 20th century changed this practice pattern however, and like many changes in human society, there were unforeseen consequences of this loosening of the prescription pen.
The first change in this philosophy of pain management occurred in the 1980’s when medical schools began to realize that they needed to produce physicians who were more than just good scientists and technicians. Schools were responding to criticism that their graduates could score high on objective tests, but didn’t always perform as well on the ‘human side of the equation.’ Administrators wanted doctors that had better bedside manners, which included communication skills and the ability to empathize with patients in distress. There was a national effort to make sure medical students had courses in the humanities, and schools began to diversify their entering classes to include those who had majored in degrees such as the social sciences and the arts, and not to have their student body with ‘hard science’ undergraduate degrees only. This movement only accelerated with the rise of Nurse Practitioner and Physician Assistant programs that prided themselves on producing graduates that really ’cared’ about their patients.
The next development in this story came about in the early 1990’s with well-intentioned advice of the influential hospital oversight group known as the ‘Joint Commission for Hospitals and Clinics’ (the JC for short). They deemed that doctors were not attending closely enough to the needs for acutely ill patients in hospital settings to have their pain needs assessed and treated effectively. The JC, which inspects and certifies the quality of hospitals all over America, rightfully admonished doctors and nurses that many times patients were in a lot of pain, either in emergency rooms or in post-operative beds, yet were being under treated for their pain. The JC proposed that a pain scale should be assessed by nursing personnel on every patient, and this became known as the 5th vital sign. In addition, physicians needed respond to this ‘vital sign’ and increase their doses of medication or provide more effective delivery of this medication to meet this very basic need for pain-relief. Concomitant with this advice was good research that showed when pts were given higher or more regular doses of pain meds in an acute setting to adequately address their pain, they did not become ‘addicted’ as providers had feared.
The last step in the evolution of this change was the development by the pharmaceutical industry of a new series of medications for long-term use by out-patients to manage chronic, and not just acute pain. The prototype that has received the most attention has been ‘Oxycontin’ which was aggressively marketed by its manufacturer with the intention that this medication could be used for a variety of conditions, from migraine to fibromyalgia and many pains in between. They asserted that these new drugs could assist those who suffered from these chronic problems to more effective manage their pain without risk of addiction, and that they could then become more functional members of society rather than be disabled by their pain. Great hopes, no doubt, but now we know that this optimism was based more on good marketing rather than good medical research.
So with the elements of this perfect storm in place, it is no surprise that outpatient providers in the late 1990’s and into the 2000’s tried hard to listen to their patients complaints of pain, worked hard to find the best new medication that might ‘solve’ the pain, and developed an entirely new tool called the ‘narcotic contract’ that they hoped would provide the benefits of these meds without the risks….And at first, it seemed to work. Patients who had been nearly incapacitated with chronic back or joint pains stated they felt great relief, able to do more than they had for years and thanked their providers for finally relieving them of their burden of pain. They told their friends, neighbors, and relatives, who in turn wondered if they too might find relief from conditions that they had previously thought that they simply had to endure. Pharmacies had to greatly increase the stock of narcotics on hand, medicine chests all over the country had extra bottles of meds labeled as hydrocodone, oxycodone and patches containing fentanyl or morphine.
So what went wrong? Well the basic pharmacologic phenomenon known as tolerance occurred, which means that the body develops a kind of immunity to these meds at the initial low doses, and higher doses are then needed to achieve the same level of relief. As patients returned to their providers, they let them know that the meds didn’t seem to work as well anymore, and the empathetic docs did the best thing they knew to do: increase the dose a little more, and the cycle continued.
Eventually by 2010 better research was telling us that these prescription practices were misguided for a large number of chronic conditions, and that other modalities such as physical therapy, cognitive -behavioral therapy, self-hypnosis, pain management with judicious use of injection treatments, and even acupuncture offered safer and longer term relief for many of these painful conditions. But unfortunately the cat was already out of the bag and there were many patients now addicted to their current and often ineffective dose of narcotic medication. And to make it worse, there were enough meds in circulation that were being shared (illegally) by well-intentioned friends, curious adolescents or taken by individuals with serious psychiatric conditions that an entire tsunami of individuals were showing up regularly at the pharmacist door to get more of the ‘good stuff’ --- with prescriptions and sometimes without prescriptions. Pharmacists have to learn to deal with forgery and robbery. Providers regularly have to rebuff skilled manipulators and those who fake or lie about their injuries. Emergency department personnel now have to send their patients through weapons screening ala the TSA. And there are now more people who die from accidental overdose of prescription pain meds in Maine than die in car accidents.
So how do we get out of this mess? It will take a concerted effort by all involved. The State of Maine has developed a ‘prescription-monitoring’ program to record all of these prescriptions and allow all providers immediate computer access to possibly squelch many of these prescriptions before they are written. Community substance abuse programs have expanded to meet the large demand of people that need help with withdrawal and substitution of safer alternatives. Neonatal services at larger Maine hospitals have branched out to serve the needs of pregnant women on narcotics to allow the innocent newborns to safely manage the transition from the womb to the world. Providers are getting better educated on the limits of narcotic medications, and the value of non-narcotic pain management. And all of us need to realize that there may not be a ‘magic pill’ to erase all our pain…..Yes, there are some good prescriptions that in appropriate doses or short term use can help us. But more is not better, and we need to recognize the limits of empathy. It is better to be a provider that offers the best advice on how to manage a problem long-term, rather than offer a short-term, and ultimately flawed treatment. As for the law of unintended consequences, it has proven itself true one more time.