A 2000 study of the New York Medical Society found that 60% of the 1320 respondents were concerned about being investigated if they used opioids to treat chronic pain for longer than a month.8 The final, and I would argue most powerful, internal obstacle that prevents physicians from providing adequate pain treatment is a fear that a patient will lie, manipulate, or betray the fiduciary trust of the physician. The narcissistic injury sustained when a patient takes more drugs than prescribed, has a positive random toxicology screen, or is found to be taking medications from another provider is greatly underestimated and much more intense when it involves narcotics, at least in part because of the paralytic influence of the pervasive "war on drugs."9Case 2: Charybdis
Mr P is a 49-year-old unemployed former mine worker who was admitted to the inpatient psychiatric facility after making a suicidal gesture ostensibly because of his unrelieved chronic pain that "hurts all over." Records were replete with drug-seeking behavior such as insistence that "only Percocet helps" and failure to follow up with counseling or rehabilitative therapy. During the past year, Mr P had begun using a wheelchair and was rarely ambulatory because of the intense pain. Community providers had prescribed the maximum dose of acetaminophen and oxycodone(Drug information on oxycodone) (Percocet), along with benzodiazepines to treat what seemed to be intractable pain. Collateral information revealed decades of marijuana and alcohol(Drug information on alcohol) dependence, with recent drinking to the point of intoxication and increasing cognitive deficits.
Comprehensive pain assessment, including neurological workup; cervical and lumbar MRI; physical therapy evaluation; and laboratory screening for rheumatological, metabolic, and other medical causes of pain was essentially negative. Pain specialists recommended humane tapering of opioids and benzodiazepines and aggressive substance abuse treatment. Cognitive and affective disturbances responded rather rapidly to reduction in narcotics.
In this case, both clinicians and patient have been sucked into the ever- expanding vortex of substance dependence with detrimental consequences for patient, family, and community. The 2005 National Survey on Drug Use and Health10 estimated that 4.7 million people had used narcotic pain relievers for nonmedical purposes in the month before the survey. Significantly, 60% stated they had obtained the drugs from a friend or relative, while about 17% stated they had received the drug from a doctor.10 A 2003 review of addiction rates among patients with chronic pain who were given opioids ranged from 3.2% to 18.9%, figures consistent with earlier studies.11
The threat of government sanction, although likely magnified in the minds of practitioners, is nonetheless real.12 As of 2005, 5600 physicians had been investigated on suspicion of drug diversion and more than 450 had been charged with illegal prescribing, drug trafficking, and even murder. Guidance from the federal government has been contradictory and intimidating, creating a climate of "high expressed emotion" characteristic of double-bind situations.13 The nadir of this confusion was the Drug Enforcement Administration's (DEA) 2004 retraction of its "frequently asked questions" document posted in the Federal Register, which had originally been seen as expressing a more moderate position toward legitimate pain medicine. The DEA indicated that the document contained "misstatements," particularly regarding physician practices that if misinterpreted could lead to increased scrutiny.14
A small group of rogue physicians running pain mills surely deserve the strong arm of the law and many others suffer from the woeful lack of continuing education, coordination, and communication between the historically separate and disparate pain and addiction communities. Others may lack the initiative, time, interest, or resources to perform the careful assessment, methodical monitoring, and intensive counseling required to safely and successfully treat chronic pain in patients using opioids, particularly those with a substance use proclivity or problem.15 However, the vast majority of physicians are simply trying to live out their oath of providing compassionate care to suffering patients.
Experts tell us that chronic pain is always partly subjective, and clinical epidemiology can never predict with absolute certainty which patient given opioids will return to the land of the living and which will go down to the street to deal death. This uncertainty places us squarely between the rock of abandoning the field of pain management and the hard place of prescription drug abuse. In my next column, I will try to chart a course between the 2 monsters and recommend psychiatrists as the most skilled pilots to navigate the straits of the dilemma.