October 12, 2012 | Posted By Jane Jankowski, LMSW, MS

A patient walks into her local Emergency Department complaining of back pain. She appears uncomfortable, and states that she was injured in a car accident about a year ago and now has chronic pain in her back. Her x-ray looks normal. She states that her pain is best managed with regular doses of oxycodone, but she ran out and has not been able to see her regular doctor for a refill. She came to the Emergency Department for a prescription instead. Imagine you are the physician. What action would you take?

a. Provide a dose of medication to the patient in the ER to be sure it will be adequate and give the patient a prescription for a couple days’ worth of the requested medication.

b. Call her regular doctor to confirm the medication and dose before providing any medication.

c. Check the state database to be sure this patient is not seeking prescriptions from multiple providers.

d. Offer only non-narcotic pain medications.

Though the scenario sounds benign enough, providers are increasingly suspicious of patients with complaints of pain requiring narcotic pain medication because of the rampant misuse of prescription pain killers nationwide. This scenario is played half a million of times over in emergency rooms across the US. None of the above answers are clearly wrong, or clearly right depending on how one views the provider’s obligation and the veracity of the patient’s claims. Providers are caught between the responsibility for treat their patient’s pain and the fear that they are either creating or feeding a dangerous addiction. Tragic stories pepper the headlines of our newspapers, such as this recent article from the Wall Street Journal, reminding us of the ravages of addition. Yet, physical pain is real, and the medications which are effective at relieving this pain are the same ones which can lead to abuse and addiction. If a provider suspects a patient has begun using the prescribed painkillers for non-medical purposes are providers equipped with adequate training and resources to address their patient’s needs? 

The CDC estimates that nearly 15,000 people died from overdosing on prescription painkillers in 2008. Provider concerns about writing more prescriptions for narcotic painkillers are well placed. But this growing epidemic can negatively impact patients with true medical pain management needs.  Patients are encouraged to be proactive in managing medical care by knowing what medications work for them and what medications do not so they can educate providers and save time and money by sharing this information up front. Yet, this direct approach can confound the issue when providers are suspicious of patients with a sophisticated knowledge of painkillers who indicate narcotics are the only tier of drugs that have been effective for them. 

Training and education about the biochemistry of narcotics in the body may help both patients and physicians navigate this complicated territory. Regulatory efforts to control the supply of certain drug types have been suggested, but meeting the needs of patients who use the medications for non-medical purposes is complex. Communities need access to appropriate resources to safely treat the complicated needs of such patients. A referral to a rehabilitation center is only a viable option if the patient can be admitted to such a program, and the criteria vary. Insurance may or may not cover such treatment if the patient has insurance at all. To solve this problem, the approach will need to be based on respect for providers and patients, meaningful regulatory controls, and funded programs that are accessible to those most in need. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

4 comments | Topics: Clinical Ethics , Doctor-Patient Relationships , Healthcare Business Ethics , Pharmaceuticals , Public Health Ethics


James Finnerty, M.D., M.A.

James Finnerty, M.D., M.A. wrote on 10/23/12 5:11 PM

This is a very difficult problem for Docs out there in primary care. I would have a contract with my patient that they will deal only with one pharmacy and I will be in contact with that Pharmacist to alert me if the patient shows up with Rx's from another practitioner. I will also have the patient evaluated in a Pain Clinic. A clause in the contract with the patient states that, if the patient seeks care elsewhere, our contract will be cancelled. This seemed to work in practice most of the time. There is no fool-proof answer. Do the best you can to help the patient with chronic pain.

Debra wrote on 04/01/13 8:01 AM

I agree but to disagree. Here's a scenario that I am in. I had this PA as my primary, wonderful guy. He was off when I ran out of pain meds for chronic pain, he swears its MS went to 7 neurologists all diagnosed me with unheard of things. My life consisted of being very active, going to the gym daily, raising two kids, worked full time plus kids sports. I loved my life. One day woke up couldn't move my legs. Stayed there for several hours paralyzed. Then the stomach flu came on, leg tremors, legs buckling, falling down. Severe pain in both legs. Then over time my leg muscles would contract, move around cramping up. Therapy didn't help made pain worse, now 9 urs later no muscles , bed ridden and suffer from taking a darn shower. Needless to say I'm luck if I take one once a week. So this doctor I saw in place of my PA was yelling at me called me a drug addict, never seen me before, broke HIPPIA laws since tHe whole office and patients heard this, then I get arrested for yelling at her plus discharged from that office plus name slandering in file. Went to a new MD was kept on meds then taking off and put on prednisone which worked. That was short time but gave doc a clue to my illness, he then transfers out of state, seen the new one in his place, she got fired, then again bc I was taking pain meds no one else there said they would perscribe so I was discharged from that office. Found a pain management doctor, she agreed my illness would only get worse so she made me comfortable. Her nurses messed up and blamed me for their wrong doing and I got discharged from her office and she refused to listen to my side, so we listened for 45 minutes of screaming from her while I sat ther crying my eyes out when she laughed at my illness. So bottom line is, still without a full diagnoses and having to drive 6 hours away just to see a neologist in hopes of one day getting one, I wouldn't have to depend on pain meds but if its going to help me get to my doctors and some what out of bed then I see no reason why I have to suffer bc of these doctors being afraid to put us on these medicines. Why put us on them the 1 st place? Why are patients being treated like this when we are suffering? I've been through the shots, epidurals, infusions and nothing worked. Now I'm trying to be sold a stimulator unit installed in my back rather than find a diagnoses. That's to extreme don't you think when you cannot have MRI,s? A few doctors suggested MS but refuse to put me on the meds, so what am I suppose to do with doctors ruining my rep, not helping me? I can honestly see why people want to end their lives. Having chronic pain and no help is pretty scary. Stress also contributes to this illness and that's all I get from these doctors. So guess who will end up in the ER? Me bc I cannot take the pain and no one is willing to help me.

Janet wrote on 09/18/13 6:07 AM

These pain management doctors should not be allowed to drop patients without giving them at least a 30 day rx. They put people on high doses for years and then drop them without any warning or rx. What is a person supposed to do then? They don't even have enough time to make an appointment much less go see another doctor. When they do go to the er or another doctor, they are labeled a drug seeker. They are turning people into drug seekers because they started them on them meds to begin with and if you disagree with them over anything then you are out and out of luck. No one is looking out for the pain patient, they are only concerned about addicts and covering their asses.
Dawn M. Hopper OhD

Dawn M. Hopper OhD wrote on 01/28/16 6:51 PM

As a psychologist, researcher, a faculty member in the SUNY system, and substance abuse therapist, I'd like to offer some common sense screening techniques.
1) Although abuse cuts across every demographic, it is least likely in patients who have a strong need to function, meet deadlines or complete career goals at a higher level (finish a report, research, novel, project, marathon..) Why? They find meaning in their work and also 'need control.' 2) Those with a higher need for control fear loss of control and may fear or be hypersensitive anesthesia or drugs which they perceive to alter their mind/thinking. 3) They will reject the idea of a higher dose of medicine or ask questions about the side effects. 4) They are motivated to stay employed or functional. They may have a stable social history and lower tolerance for risk, 5) They may be less likely to press for pain medication until the need is severe, 6) Family members will collaborate the level of their pain. 7) There is a rapid decline in quality of life.

The danger of pain in lowering quality of life is evidenced by the suicide rate among highly functioning individuals whose needs are not being met and no longer find meaning in life.

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