Confronting the opioid dilemma

This essay is part of Medical Economics' 2013 Physician Writing Contest. Click here to enter the 2014 writing contest. 

When I graduated medical school, I distinctly remember reciting the Hippocratic oath. I was a little disappointed to learn that primum non nocere (“First, do no harm”) was not actually part of the oath. (It is still attributable to Hippocrates, but from a body of work other than the oath itself.) Non-maleficence is, however, one of the basic tenants of medical ethics, along with autonomy, beneficence, and justice.

Balancing non-maleficence and beneficence can be challenging to say the least, and most certainly is part of the “art” of medicine. I find that I face this challenge often when I am treating patients with controlled substances- especially opioid medications.

Balancing treatment and risk of abuse

I know I am not alone in struggling with how to best prescribe some of these medications; there is a plethora of literature describing medico-legal ramifications, appropriate and inappropriate uses, and proper diagnoses. The fact is there is little evidence to support the use of daily opioid medication for non-cancer pain, yet millions of people in this country use these medications for everything from low back pain to arthritis to mysterious unidentifiable abdominal pain. And the doctors that started these medications were all practicing under the tenant of beneficence.

No one likes to see a fellow human suffer, but what is the best way to really help? I know of colleagues that simply no longer write chronic opioid prescriptions. For me, that is too black and white. I know there are people that benefit from daily use of these medications, take them as prescribed, and increase their overall health and well- being by appropriately treating their chronic pain. I also know there are far too many doctors who are willing to prescribe these medications without much thought to the consequences for the patient’s life, so I made a conscious choice to examine my pain management practices. 

The first patient to cause me to critically evaluate the use of daily opioids was a young woman who suffered from juvenile rheumatoid arthritis. We will call her Julie. I had been out of residency only a couple of years when I met Julie. She came to see me a few years after her diagnosis with juvenile rheumatoid arthritis. I met Julie’s mother after volunteering to do some educational talks at a local school, and she thought I might be able to help sort out some of Julie’s health issues.

Julie suffered from joint pain-a lot of joint pain. She had been to see multiple specialists, had suffered from pericarditis, and had been hospitalized multiple times with side effects and symptoms both of her disease and its treatments. In short she had endured a great deal already at a very young age.

What I first noticed when I met her, however, was that Julie was barely able to stay awake. Her mother did most of the talking for her, despite the fact that Julie was in her early 20’s. Furthermore, Julie kept a notebook with her at every appointment to help her remember things to discuss with me, including basic symptoms. When I looked at her medications, I quickly realized why. I had never seen anyone on a dose of oxycodone so high. At one point she was taking over 300 milligrams per day, with additional short- acting medications. In fact, she wasn’t really sure how much she was taking since she hardly kept track anymore. She was just taking pills all day long trying to “ease” her pain.

Next: Confronting a crisis

Confronting a crisis

Julie and her mother recognized that this intelligent, beautiful young woman had been turned into a drug-addicted zombie unable to communicate her own symptoms at a doctor’s visit without notes. Neither, however was convinced that stopping the medication altogether would actually help.

Julie and I struggled to understand this disease together. I did more research on pain medications and their side effects when Julie started experiencing seizures and thyroid problems, and stopped having her period-all attributed to the high doses of opioids she was taking.

When we started lowering her doses many of these issues went away. She started to have a personality, and it was actually fun to watch her reemerge. Through many visits, many compromises, and frequent tears from both of us, we managed to get her down to less than 150 mg of oxycodone daily, put her on a regular schedule of opioid use, and see a substance abuse counselor to help her deal with the addiction side of her treatment along with the chronic pain.

Even though she knew things were bad, these were not easy changes for Julie to make. She was so afraid to experience pain the way she had when she was first diagnosed, so afraid of being left without treatment, it took months to get her to start decreasing her doses. Although she acknowledged the positive aspects of reducing her pain medications, she did not see any potential benefits from weaning or stopping completely. I strongly encouraged her to change her diet, exercise more, and learn tai chi, most of which she made feeble attempts at, but didn’t stick with.

I made a point of celebrating the small victories with her. I celebrated when she was able to finally attend a baseball game again, and I will never forget the joy on her face when she told me about running to catch a United Parcel Service delivery person-the first time she had run in years.

Julie’s mother once told me that she harbored guilt for pushing Julie’s previous doctor to treat her more aggressively. But she couldn’t stand watching Julie suffer with so much pain. How different would Julie’s life have been if she had been sent for mindfulness training, for tai chi training, for counseling to help her manage living with chronic pain at her first diagnosis instead of being put on ever-increasing doses of opioids?

I admit that at times I blamed Julie for wanting an easy way out and for her addiction to the medications despite all of the negative side effects and evidence that they were not helping her. But really, why is it her fault? She was following her doctor’s directions to stop her suffering and who can blame her for being afraid of that kind of pain again? None of my suggestions were as quick and easy as taking a pill, and she was incredibly brave in trusting me throughout our relationship to continue to cut back on her medications without knowing how she would feel.

Next: Learning more about chronic pain management

Learning more about chronic pain management

I have had countless other patients since then whom I have felt much more confident in maintaining on lower doses of opioid medications because of Julie. I also have educated myself on better ways of managing these medications and chronic pain. Although not everyone is happy with my philosophy of care, I certainly have met patients that make me realize that I am not wrong to offer alternatives and refuse certain treatments.

Recently I had a new patient, “Kate,” walk into my office. She was previously seen by my partner. The old notes said Kate had come in asking for a refill of oxycodone while she was in town for a funeral. My partner had refused the refill without any past records, and the only diagnosis left in Kate’s chart was “drug seeker.”

When I met Kate 2 years later, she had moved back to the area and her medication list now included a long-acting morphine in addition to the oxycodone. As Kate told her tale of being diagnosed with degenerative joint disease in her neck and back, followed by a diagnosis of fibromyalgia, I was already mentally practicing my speech about how opioid pain medications are not ideal for this type of pain and that there are many harmful side effects that can be avoided with alternative pain regimens.

Next: Weaning off pain medications

Weaning off pain medications

I explained that I would not recommend these medications for her diagnosis, but I could fill a small prescription to help her wean off of daily use. She stopped my rehearsed speech and said she hadn’t been on the long-acting morphine for the last 2 months and was hoping not to start it again. She was OK without a refill of oxycodone as well, and wanted alternative therapies that wouldn’t leave her feeling doped up or like an addict. Kate was willing to suffer with more pain if she could be functional and live a fuller, richer life. What a different outcome than what I was expecting from the visit!

In subsequent visits Kate still has not asked for any opioids. In fact, she has thanked me on multiple occasions for taking the time to listen and not simply push drugs on her that she does not want-a very different approach from how she felt she had been treated in the past. She was always open to alternative methods of coping with the pain, but no one had taken the time to listen to her before-perhaps because writing a script is a faster way to get on to the next patient, a mistake I almost repeated.

Despite the fact that Kate was ready to accept other treatments by the time I met her, that visit-and therefore her life-could have gone very differently. I could envision a scenario in which I was in a hurry that day and didn’t want to go through my whole speech. I could have simply filled her prescriptions and she may have taken them, thinking that drugs were the only alternative because that was what every doctor offered.

Without seeing the harm that had been done to Julie, I don’t think I would have developed the protocol for managing pain that helped me not jump to a prescription for Kate. It is undeniable that our patients affect our practice: these two women may have never met each other, but I like to think that Julie’s suffering from an addiction helped Kate to avoid the same.

Remembering the lessons 

I have not forgotten the lessons from Julie or Kate when I see patients in pain. I do my best to discuss realistic, functional goals of pain management and to develop a written plan of care and treatment agreement to review with each patient. I discuss my philosophy that daily opioid use is hazardous, and should be minimized or completely avoided whenever possible.

I frequently ask myself whether I am creating an addiction and therefore doing more harm than good with my opioid treatments-even when the patient insists that these drugs are the only things that help as they look to me for relief.  Patients suffering with severe pain can complicate treatment further. If they feel you have an easy cure and are keeping it from them, it’s more difficult to convince them that mindfulness and exercise will eventually help them with their pain-just not in the same way as the instant relief from taking a pill.

It has taken much time, learning, and practice to feel more comfortable with these patient scenarios, and I still encounter challenges and ethical dilemmas with each new patient. But having learned from one patient’s suffering I believe I can help others avoid it.

Sir William Osler, the “father of modern medicine,” said, “As physicians we should strive to cure a few, help most, but comfort all.” There are so many medications and treatments available to us as physicians today, but at what cost? Perhaps when considering our ethical questions of beneficence vs. non-maleficence we need to remember that although we have access to medications that can ease suffering, there are consequences and trade-offs to using them. Most of our patients will land in the “comfort all” category not by what we prescribe, but by our offering an empathetic ear, listening to their story, and discovering what they, as individuals, really need.