When was the last time you used any narcotics? I think I took some of my mom’s cough syrup with codeine over a decade ago, when I felt like I might actually cough up a lung. Before that it was one dose of Darvocet after having four impacted wisdom teeth extracted at age 18. I don’t really remember much after swallowing the pill and lying down on the sofa. I was given multiple opioids during knee surgery last year, but needed only Tylenol and Advil afterward. Looking back on the post I wrote about that experience, I realize even more how I was influenced by this piece in the New York Times just a month before my surgery. In it the author is reminded that pain serves an essential purpose, and it’s better that we not necessarily seek to obliterate it at every turn.
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Four or five times in the last two weeks, I have received calls from local pharmacies to confirm opioid prescriptions that I did not write. They were all paper prescriptions for patients I have never met, caught by astute pharmacists who suspected fraudulent activity. This is the first time it has happened to me, and I know many of my colleagues have experienced the same. Pharmacies in the area have now flagged my name and license number, and they know not to fill any controlled substances without direct confirmation from me.
What a morass. How did we get here? It’s a rhetorical question, really, but not a simple one by a light year. When I started my training, we were taught to consider pain the ‘5th vital sign.’ Every patient assessment included the cartoon face pain scale. Anesthesiologists’ prioritized rubrick for pain control started with long acting opioids around the clock, then regular anti-inflammatories if no contraindications, then short acting opioids as needed for breakthrough pain. In the hospital I never questioned this method, especially since I almost never interacted with these patients after discharge and was oblivious to follow up issues.
It was not until I started in practice that I experienced the multidimensional challenge that is pain control and opioid prescribing. After 15 years I am still learning the layers of complexity, unique for every patient, and I see that even if we understand it (which I think we do not), most of us feel helpless to address it.
The pharmacist I spoke to today told me that his store’s standard procedure is to inform the patient that the prescription was proven to be fake, advise the patient not to attempt such an act again, and let them know that the prescriber is aware and the police will be contacted. It was that last part that made me pause. Because even as I intend to file a police report (as advised by my institution), the answer to the problem is not, in my opinion, rounding up patients with chronic pain and throwing them in jail. In order of importance, I think the opioid crisis is first a social, then a medical, and only then, a criminal problem.
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Increasingly, we have become a society of immediate gratification and entitlement. We want and expect a magic pill for and complete relief from whatever ails us—because it’s the twenty-first century for crying out loud, how could we not have that already? Also, medicine has become increasingly transactional. We, patients and physicians alike, experience ‘care’ in predetermined packets of protocol and procedure, and spend considerably less time in conversation, education, expectation setting, and actual caring. The advent of the internet has accelerated this immediate gratification expectation. It also gives many of us an illusion of connection through social media, when in reality, we are actually less and less connected to one another.
Pain results from myriad causes. We all have varying thresholds for feeling and tolerating pain, which vary themselves depending on circumstances, mindset, expectation, and meaning making (think childbirth versus bike accident). There are so many factors that impact our pain experience, including dehydration, sleep deprivation, low mood, and emotional and/or mental stress. Loneliness, depression, anxiety, sleep disruption, suicidality, and substance abuse are all on the rise. And all of these conditions lower our thresholds for pain and the harm it does to us.
For many, opioids are indeed the immediately gratifying magic pills. But the magic wears off faster and faster, and both pain and the desperation for relief accelerate in the wake of short and long term withdrawl. As physicians, we feel an intense desire to alleviate suffering. Once a patient has experienced the profound relief (both physical and psychological) from opioids, it feels cruel for us to withhold them, even when we understand fully their risks and the long term harm they cause. And we have less and less time to explore with and educate patients about adjunct pain management practices, such as mindfulness, biofeedback, and movement. Everybody feels despairing and impotent, and this drives people to do things they might not otherwise do, like make a fake prescription for hydrocodone and try to get it filled.
I know there are real criminals out there, people not really in pain, who do this to make money—to take advantage of people in real pain. I don’t know who’s who. But the story I tell myself is that this is not most people. What we need is a stronger infrastructure to address chronic pain at multiple levels—individually, in community, with policy, and culturally. As I write this, even as a physician with a leadership title, I feel powerless and a little hopeless.
But maybe a good start, at the individual level, that we can each do the next time we look ourselves in the mirror or meet another human being on the street, is to just exercise a little compassion and generosity. I assume that those patients presenting the fake prescriptions, if they are real patients, are not criminals at their core. Pain makes us do unthinkable and unbelievable things. I hope we can all help one another find better sources of relief and support.
As far as the fake prescriptions are concerned, although it’s true they might have been filed by people in genuine need, I think it right to contact the police because:
1) The next time it might be something more dangerous, or their need might not be so great, but they feel encouraged to try again having got away with it, and
2) It is very possible the prescription might be one of ten or twenty or mile submitted by someone intending to sell them on and make money.
Agreed. Filing police report soon. Have a great evening, Mick!
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Thanks, Catherine. You, too.
Very thought-provoking post Dr. Cheng. I have people in my own family that suffer from chronic pain issues, even our dog with hip displasia requires the help of Tramadol at times. Even our vet is affected by the increasing restrictions on writing scripts for these medicines. I don’t really know what the solutions are for our society to get through this. It is making it harder for those having to deal daily with pain management.
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Thanks for reading and commenting, Mark. A colleague and I are messaging on Facebook today about this. I wrote that we should be transitioning patients off of opiods onto other pain management strategies. She asked, transition them to what? Below is my response; wonder what you think?
“That’s the million dollar question, right?? Other medications, resetting expectations for pain relief, mindfulness to cope better with the pain they have (ample evidence for MBSR programs for this), complementary and alternative approaches such as acupuncture, hypnosis… Cannabis? There are so many options, and it all takes time and engagement by both provider and patient to explore, and then accessible resources for the patient to try–no wonder we all feel so helpless and desperate! I think the most important factor, though, is the therapeutic alliance between patient and physician. We have to see our patients as whole people, people who suffer not just physical pain but all kinds of other pain, and we have to find a way around our judgment and biases–no small task. Patients need to feel that we are on their side, and also that we uphold standards of care and professional integrity. Yeah, easy–NOT. It will really take every participant in the system to change–the system will not change itself…”
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I do like the alternative approaches, but then they frequently involve going to see a variety of practitioners and sometimes the necessity of many follow ups to judge effectiveness at best, or a series of trial and error at worst. A lot of people just don’t have the time, ability to schedule around their busy lives, to have it be this long process. Like you mentioned, the solution in a pill that is effective not only holds power of pain management, but also convenience.
Agreed. Would that there could actually be a risk-, cost-, and consequence-free magic pill…
On the other hand, there probably still is a place for opioids on the spectrum of pain control/management strategy. We just have to realize and respect the profound risks.
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Chenger, you have written many good pieces but this might be your best especially coming from the viewpoint of a doctor.
I remember after Lauren’s birth I tore a muscle in my abdomen. My OB wanted to prescribe medication for the intense pain. My answer was that the pain was letting me know my limitations so I refused.
We do all after different pain thresh holds, but this is a problem needing to be addressed immediately and from multiple sources.
Thanks for your input. Hugs.
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Thank you, Dawn!! Miss you so much! Not sure if you followed the link to the NYT article, but based on your comment here, I bet it would resonate with you. Hugs back!! 😀