Tuesday, August 28, 2012

Confession of a narcotic over-prescriber

I graduated from Medical School in 1985.

Here are some of the reasons I was so accepting of narcotic use for the treatment of chronic noncancer pain (CNCP) starting in the late 1990's.

      * The World Health Organization developed the 3- step ladder for cancer pain relief in 1986 (over time it became widely used for the treatment of all types of pain).
      * A study of 10,000 dying patients published in 1995, in JAMA, in which researchers found that almost half of the patients died in severe pain.
      * In 1998, a working group in Congress was established to examine what role the federal government should play in alleviating pain and in other end-of-life issues.
      * Position statements by various organizations that usually included a summary statement such as: “narcotics are underused and have low addiction potential when used for CNCP.”
      * Numerous CME conferences for catch-up education. No "ceiling dose" for narcotics was emphasized. I remember how impressed I was at one particular case study in which an elderly woman was taking over 1000 mg of morphine/day, for severe DJD,  and remained functional and independent.
      * Mini-fellowships for the treatment of pain became available. In the early 2000’s, a colleague became a "pain specialist" after spending 4 days with a pain team.
      * There was little noticeable support for primary care providers in the early days.
      * Private pain clinics appeared in abundance. For awhile, there were more pain clinics than cash-advance shops or pawn shops around our city.
      * Non steroidal anti-inflammatory (Vioxx, etc) and acetaminophen (Tylenol) scares.
      * Delays in obtaining many complimentary services (PT, pain anesthesia) and the unavailability of many other services (chiropractic, massage, etc.).

So, fast forwarding to now.

A quote by Maya Angelou is very appropriate: “I did then what I knew how to do; now that I know better, I do better.”

The efforts by various authors/educators have been very helpful, including an article this month in American Family Physician: Rational Use of Opioids for Management of Chronic Nonterminal Pain.

The efforts by Physicians For Responsible Opioid Prescribing (PROP) are also greatly appreciated.

One member, Jane Ballantyne MD, a pain specialist from Seattle, WA has stated, “we started on this whole thing because we were on a mission to help people, but the long term outcomes for many patients are appalling, and it’s ending up destroying their lives.”

I now have access to vastly improved pain management services.

As a Primary Care Physician, it feels as if the pain cavalry has finally arrived.

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