Quoted: Pain management and medical school

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I was recently accepted into medical school. My joy has been tempered by apprehension, however, as I'll explain below.

Due to a congenital joint disease, I suffer from chronic pain. Until recently, it was not a major issue. I could get around decently and only needed some tylenol/motrin. The joint pain has been increasing, however, and I started on pain management late last year.

I take about 30-40 mg oxycodone and one 325 mg of carisoprodol a day. Contrary to what you think, my meds don't make me sleepy or slow and I still perform at a high level. If you met me, I doubt that you'd even notice; I performed most of my interviews last year while taking medication, and managed to obtain multiple acceptances. They just let me function normally, without the constant joint pain.

I am not worried about the effect of the mediations on my performance, but rather I am worried about what my medical school will think about them. I know that medical records are private, but I am drug-tested, I'll hae to give them my prescription record. Moreover, a faculty member might very well look it up on their own.

I know that many physicians look down on opioid painkillers and the patients who use them. I don't want to look like a drug abuser.

I'd like an opinion from someone with more knowledge of the workings of medical school. Should I stop taking opioid medications and try something else? Am I putting my professional future at risk?

Thank-you.

A complicated question. The question is not whether you being worried about whether your medications affect your performance. Most heavy drinkers don't think that their drinking affects their driving, for example. The question is whether others will feel the same.

More broadly, the question is whether it's safe to be a physician while being on narcotic pain medications. And you could replace "physician" with airplane pilot, school bus driver, etc. Are you really safe to be in the OR? etc. On an even more basic level, is it safe to allow patients to drive while they take narcotics? And if so, is there a maximum dose? There are no answers to these questions.

There is the flip side -- if you stop your meds, perhaps you'll be in increased pain. That might degrade your performance. It's possible that it could be worse for you to be off medication than on medication from a safety standpoint.

In general, having treated physicians and nurses on narcotics, the current feeling is that this is usually OK. Your treatment can't interfere with your performance, but you're "innocent until proven guilty".

The process will be like this:

When you enroll in medical school (or get into a residency, or get a job), there is certain to be a health questionnaire asking about health issues and medications. A department of occ med will process this. You will almost certainly be required to see someone in occ med to discuss this. You'll disclose it, and it will show up on your drug test. Occ med will certify that you passed your pre-employment medical exam (i.e. no one else in the school/hospital will know that you're on meds).

Occ med records are often kept separate from your medical records. If anyone at your institution were to actually look in your records, that would be a major HIPAA violation and would likely get them fired.

There are some fields which are probably best avoided. Anesthesia has a very high rate of drug abuse, being on chronic narcotics and being in anesthesia is probably best avoided if possible.

You'll also have to consider where you'll be in 10 years. If your pain worsens and your dose escalates, how high is a "safe" level? Again, no answers, plus who knows if your disease will worsen or not.

The other thing to consider is that in the event of any malpractice allegations, will your medication use be discovered, and how will it affect the outcome. I am lucky enough not to have any chronic pain issues, but for various acute pain issues I have been given narcotics and have a very high tolerance. I can understand the assertion that you are able to function well on your meds, as I have also felt I was functioning normally on oral pain meds-to the point of feeling safe driving a car, etc. But, I always thought any use wasn't allowed though and therefore never worked as a medical professional while taking any opiates (although I have worked after taking flexeril once-which I understand sedates some people greatly). I don't think it is technically true (tried to find a reg about it in California and couldn't find anything that wasn't vague), but if any incident were to occur-even if it wasn't your fault-a lawyer would probably lick his chops if he found out you were "high" when it happened. If there is any other way to control your symptoms I would recommend you try that instead.

Posted for a user anonymously:

Hi - I am in a similar situation. I have a Ph.D. in physics but as time goes on, I would really like to work in clinical medicine. I take chronic opioids, and have for several years. Before I take on a large medical school debt, I would like to find out more about whether I'll be able to work freely or not.

Are the documents from occupational medicine public? I ask because if a malpractice suit is brought against me, will lawyers be able to find out I'm on opioids? I don't think I would fare well then.

Are there any other hindrances to completing medical school, selecting the residency of my choice, and practicing in the field of my choice and in the state of my choice, while using chronic opioids? (I'm in the Boston area and if I had it my way, I would stay in the Boston area for the rest of my life)

I would appreciate any other information you could give, or any contacts that I could reach out to. I would like to feel more confident that I'll be able to practice medicine freely, before I take on medical school debt.

Thank you.

Your medical records are not public record. They are private.

However, these things tend to be found out anyway. It only takes someone who knows telling someone else, telling someone involved in the case, and the defense finds out about it. Once they start poking around, you can try to claim privacy but often that just makes you look like you're hiding something.

That being said, there are probably plenty of physicians who practice while using narcotics / benzos / anti-seizure drugs / medications which could be implicated in impairing their functioning.

You are likely to run into roadblocks. You will be drug tested, and will of course be positive. You'll then be assessed by Occ Med to decide whether it's acceptable or not. This same process might be repeated when you apply for a license, or when you try to get a job. If you fall asleep in lecture (not uncommon in residency), someone might assign blame to your narcotic medications. Whatever pain syndrome you have might be exacerbated by residency -- back pain doesn't tend to do well with long shifts, for example. SOme fields, like anesthesia, might be completely off limits (as this field has a high rate of drug abuse -- although using narcs for a medical reason shouldn't increase your risk of abuse, others might not see it that way). Whether it would be safe for you to do surgery while on narcotics is an open question -- as you mentioned yourself, it could be blamed for any perceived problem that occurs from your care.

You could also fly right through medical school and residency without a problem.

We'll see if any other SDN'ers have any personal stories to share. If you want them posted confidentially, simply indicate so in the text, or PM them to me.

The mere fact that you are being treated with opiates for chronic pain ought not summarily disqualify you from becoming a physician or practicing medicine. I've known a few good docs who were taking such meds for chronic pain; indeed, one of my best teachers had advanced MS and had a great deal of spasticity and visual impairment, but he was still able to perform quite well in his specialty (PM&R). A lot depends on your specialty in medicine. If you are spastic, have a bad tremor, or some other specific physical disability, there are certain things that will be difficult or impossible for you to do. You might want to be an eye or microvascular surgeon, you have a bad essential tremor you'd have to give up that goal...

There is a difference between taking prescribed opiates for chronic pain and being "addicted" to narcotics. Opiates are characterized by their ability to induce tolerance and dependance. These are pharmacologic/physiologic characteristics, along with specific other "side effects" (such as constipation, respiratory depression, nausea, and pruritis) of this drug class. All of these things are individually variable.

Addiction is a risk of narcotic medications, but it is an individually variable risk. Some people (those with so-called "addictive personalities") are more susceptible than others to addiction. Addiction is a behavioral pathology characterized as a compulsive use of narcotics (or some other drug or anything else...such as sex, gambling, etc.) despite adverse consequences.

I'm sure that many here on SDN are fans of the TV series, House, MD. I admit to enjoying the show, but I have misgivings about it. Dr. House, IMHO, is an addict and, despite his being portrayed as a brilliant and heroic diagnostician, is clearly "impaired." He's also clearly suffering from a severe case of Narcissistic Personality Disorder and probably also ASPD if not outright Psychopathy....But what do I know...I'm just a neurologist. Some of my psychiatry colleagues may wish to chime in...

Posted by request of the above user

Thanks for your reply. Regarding drug testing: I am not sure if I would come back positive. I am unsure what type of drug screen they do, but I have taken several drug screenings before and they did not detect opioid in my system. I have read that semi-synthetic opioids, e.g., Fentanyl, may not appear on a drug screen. Morphine, on the other hand, will. I assume I have to tell occ med what medications I am taking (so the drug screen is simply a formality and I’ll still need to explain the situation)?

If I do not show positive on a drug screen, will I need to meet with occ med? In any case, how does occ med decide if I can practice medicine? Is it always occ med diciding (throughout my career, e.g., residency, getting an attending job, etc) or are there different departments?

I am interested in neurology and anesthesia. With respect to anesthesia, I actually find pain very interesting. I have thought about it a lot and I do think that I am interested in anesthesia not just in terms of myself. I realize there is a problem with drug abuse in anesthesia. Can you tell me why this field would be off limits? Who would decide this? Occ med?

I really cannot believe an organization would think that someone would spend 4 years going through medical school just so they have easy access to Dilaudid, etc, because now that they are in 200k in debt from med school, the only way they can afford to “score” is at work. I don’t understand it? I’d be more concerned with auxiliary staff with access than doctors who have made this their life’s work. I do appreciate that some anesthesiologists have become addicts due to ‘easy access’ but that shouldn’t cause a black mark for all— just like the fact that some opioids users get addicted should not dictate that physicians never prescribe opioids.

I digress...

If anesthesia is off limits, I would love to purse neurology. Pain issues in neurology are fascinating as is aging and its effects on the person. Would neurology also be an area that raises red flags?

I am unsure if I could use my knowledge of rtfMRI technology to do research in neurology and/or anesthesia (not necessarily in the pain subfield), but if I could, I would love that! Can you offer any advice for someone with a Ph.D. in a hard science already who would like to do medical research (after receiving an M.D.)?

First, you should assume that ALL substances will show up on your drug screen. You are incorrect that synthetics do not show up -- fentanyl is definitely on our usual drug screen here for patients. Understand that if you are on a substance legally, don't disclose it in advance, and then it's found on a screen, it is likely NOT going to be acceptable.

If you're on a chronic narcotic and your dose has been stable and you have a physician giving it to you, you should be OK. However, each institution will look at this differently.

Of note, there is no requirement to disclose this up front. You are welcome to interview for positions and not mention it at all. However, you then run the risk that during the credentialling process you might run into trouble.

If you're working at a large institution, they will have a standardized way to deal with this. Occ Med or HR will have a process. If you join a private practice, there won't be any of this and you'd just be hired.

Somewhere along the line, you'll need to get a medical license. Your narcotic use will be disclosable then, but again as long as your dose is stable and you haven't run into trouble, you shouldn't have too much trouble. You should assume that it will take twice as long as normal to get licensed, and perhaps require a personal interview by the board -- but that will depend on the state.

Anesthesia will be a touchy subject. The rate of substance abuse is higher in that field. The question is whether your chronic use of narcotics makes you a higher risk for abuse. There is no clear data on this that I know of. Some would argue that it actually lowers your risk of abuse -- that if you've been stable for some time that it "proves" that you won't end up in a spiral. It will make any drug screen less "helpful" as it won't be able to separate your normal med use vs abuse of the same med.

Neuro will not have those problems at all.

There are lots of ways to get involved with research, but I am probably not the best person to review all of that. You could apply to a "research pathway" residency, or simply do a post-doc after your residency, or if your pre-residency research is impressive enough you could simply apply for grant funding.

Old post, but in case you are still there...As a grad bioethics student, I went on opioids. I asked for and took an occupational evaluation. It was pretty extensive, covered cognitive, physical, etc. Could something like that be possible for you? I still use my better judgement, and ethics consults are not neurosurgery.