Don’t feel alone. This doctor is worn down and just saying no. Opioid poisoning as a cause of death more than tripled in the US between 1999 and 2006. Death from prescription opiates is now more common than death from heroin and cocaine combined. (USA Today)
Today a new patient came to the office looking for a physician to prescribe the opiates she wanted to take for her fibromyalgia, interstitial cystitis, and chronic low back pain. She proceeded to say she just wished the good doctors who had previously been prescribing her massive doses of opiates were still around. She thinks one of them must have done something wrong, because his office was just closed down suddenly and all his medical records were taken away. I’m sure this is the Lakewood, WA physician who lost his license for inappropriately prescribing opiates. She was a caricature of the opiate-seeking patient. She had not just one of the ill defined painful conditions that are impossible to exclude, but at least three. She had been prescribed both Oxycontin, as well as large doses of “breakthrough” oxycodone. I am not accepting new pain management patients into my practice. This made it easy to explain that I would not be able to treat her for these problems with opiate medications. Actually the abuse of opiates have become such a rampant problem that I don’t know of a physician in the county who is accepting new pain management patients. This is sad for patients new to the community with legitimate need for pain medication, but just an impossible position for physicians. Any physician who becomes known as accepting chronic non-malignant pain patients would be quickly overwhelmed by the droves of new patients needing pain medications who would show up to receive care. Years ago a wise older physician (he was probably as old as I am now, and likely far wiser) told me we all have our albatrosses. These he described as very needy and difficult patients that you’d just like to find a way to get out of your practice. He explained that if we all just keep a few then no one will be overburdened with too many. Otherwise they will just keep circulating in the medical community, and all of us will still need to take care of them. It’s best to just buck up and keep doing our best for them. These days I feel like these patients are not like rare albatrosses, but rather like common crows, just everywhere, and dashing in to pick me apart like road kill.
There seem to be so opiate seeking patients now that an open door to see them would just overwhelm anyone. Cynically yet realistically I know that this is in part because no one physician will knowingly prescribe the quantity of drugs that they want, so they need to have multiple physicians prescribing their meds who are unaware of each other. (this problem to be the subject of another post soon) Anyway this episode made me smile because this patient was either incredibly naïve, or a very good actress. I suspected the latter. Most opiate seeking patients are very smooth and make me at least feel like maybe I should try to help them by seeing if I can help them manage their pain with less opiates and good care. In my experience this very rarely works, because the customer really just wants the drugs. I know that although there are some patients for whom opiates for non-cancer pain is the best available treatment, there are so many professional patients who resell the drugs on the street and others who are addicted to the meds and overuse them in vast amounts, that as primary physicians we are in an impossible position. We either become suppliers of the prescription drug culture, or we turn away some appropriate patients. Which is worse? This depends on your viewpoint, but at this point I generally just say no.