Sunday, June 25, 2017

Why I Don't Prescribe Pain Medicines

It may seem strange that a gastroenterologist like me does not prescribe pain medicines.  Let me rephrase that.  I don’t prescribe opioids or narcotics.   I write prescriptions for so few controlled substances that I do not even know my own DEA number.  You might think that a gastroenterologist who cares for thousands of patients with abdominal pains would have a heavy foot on the opioid accelerator.  But, I don’t.  Here’s why.

I truly do not know my DEA number.

I believe that one person on the health care team should manage the pain control.  In my view, this should be the attending hospital physician or the primary care physician in the out-patient setting.  There should not be several consultants who are prescribing pain medicines or changing doses of medicine prescribed by another physician.   With one physician in charge, the patient’s pain is more likely to be managed skillfully while the risk of fostering drug dependency and addiction is lessened.  We all know addicted patients who obtain medicines from various physicians and emergency rooms.  It’s cleaner when a patient on pain medicines knows that a single physician is in charge of managing this issue. 

While my argument of single physician authority can be applied to other medical conditions, this is even more important with narcotic agents.  For example, if a patient has an internist a cardiologist and a kidney specialist, only one of them should be managing the patient’s high blood pressure, at least in my view.   Since narcotics and related medications have addictive potential, it is even more important to have a limited prescribing source for patients. 

When I am seeing patients with abdominal pain, particularly in the hospital, I’m often asked for narcotics or to increase the dose or frequency of pain medicines that were already prescribed.  I counsel these patient that the attending physician is in charge of this and that the patient should discuss the request with this doctor. 

Other gastroenterologists and medical consultants may approach this issue differently.  I’d love to hear from them or from patients who have faced this issue. 

We can all agree that pain is the enemy.  But, the medical profession in its zeal to eliminate it, has contributed to the ravages and suffering of drug addiction.  In my state of Ohio, we lose thousands of our people every year to drug overdoses.  For many of them, their tortured path toward agony started with a medical prescription prescribed by a doctor like me.


Joan B said...

as a patient my only concern with your approach is that you are counseling the pt to ask the attending. the biggest problem i have with my own health is that my docs do not talk to one another. Imagine being in a lot of pain. You may or may not be awake when the attending drops by. Imagine being 85 and not having all your abilities. Why can't you pick up the phone and talk to the attending and let him or her know that the pt is in a lot of pain and that you are deferring to the attending on this issue? thanks for the oppty to express my thoughts!

Michael Kirsch, M.D. said...

@Joan, thanks for your thoughtful points on this issue. I agree with you that a consultant physician who is being asked for more pain medicines should either get in touch with the attending physician, or direct the nurse to do so. In my experience, the treating nurse has already contacted the attending doctor before I come to see the patient. This issue is often further complicated in that there are patients in the hospital who are addicted to pain medications and complain of pain despite high levels of narcotic medications. In my view, these circumstances call for a pain management specialist to provide necessary guidance. I also agree with your underlying premise that communication among medical practitioners can be improved.

Anonymous said...

Dr. Kirsch,

As a survivor of necrotizing pancreatitis, and speaking of life outside the hospital, I find the lack of connection between the gastroenterologists and the chronic pain doctors frightening. I suffer from severe episodic pain every time I eat, yet the chronic pain doctors seem disinterested in the root cause of my pain and look only to create more long-term, systemic pain relief. I personally don't think the gastroenterologists should abdicate their role in patient pain control, but rather insist that patients on long-term opioid treatment also be enrolled in chronic pain programs. I believe in the efficacy of the chronic pain physicians and psychologists, but their lack of knowledge in abdominal issues cripples their ability to be effective for their patients. I trust my gastroenterologists with my life.

Thank you for the opportunity to comment. Keep up the great work on the blog.

Anonymous said...

I have changed my practice over the years to follow the same opioid prescribing practice that you describe. My life has become much easier. As a consultant, when a chronic opioid user comes to me I consult on the use during pregnancy, but all refills are referred back to the original prescriber with recommendations. I have the additional advantage of nine month limited consultation.

There are certainly acute events that I take care of and prescribe short course therapy but that is when I am the attending hospitalist or in a limited procedure mode. I have the additional advantage of an HMO with a single silo for pharmacy and outpatient and inpatient care provider EMR. Patients shopping outside of the HMO for pain meds are identified by a Statewidow non-HMO opioid registry for all pharmacies. The interface between the two EMR for drugs should improve with time. Regulatory fears of the State do not allow for ease of use at this time.

Tim Clark Sr said...

As a person with Ankelosing Spondilytus for 17 years I have had every opiod on the market. Recently I was able to get off of them. On my best old day my minimum pain score was a 2.. now with no pain opiods, i have no pain and my pain score is 0. That tells me that opiods keep your brain hightened to pain.
These ruined my finances and broke my spirit.. However, now I am getting stronger each day and have hope.

Michael Kirsch, M.D. said...

@Tim, congratualations and best wishes on your accopmplishment. I'm sure you can inspire others.

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