You know what I'd always like to ask MDs? Why do you care if a patient wants to stuff themselves with opiates??? Do you HONESTLY care about that patient on a personal level? Are you going to go home at night and worry about him/her? Do you concern yourself with how much alcohol they consume or whether they put tattoos on their bodies or get their ears pierced or wear their seatbelts? Are you going to phone that patient at home to check on him/her? Are you even going to think about that patient a single time after they leave your office? No, you aren't. Seriously. And you know it. (And, yes, I am a real psych student, not a "junkie," although I do love how you "professional healthcare providers" talk about/label your would-be pts.)
What med school is
clearly failing to emphasize is the treatment and follow up of patients on a psychological level. There is as much (or more) psychological pain in the healthcare world as there is physical pain, and we are beginning, in fact, to learn that the two are very often linked; psych pain can manifest physically. Ever see the Cymbalta commercials? But you guys get a patient who is in psychological pain, is seeking attention or medication by going to the ED (those "frequent fliers" you all love so much), has hurt themselves in some way (boy, do those patients get treated nicely!), and you begrudgingly treat them to whatever extent they need or that you are willing/forced to by law, and then pass them off to Psych or blow them off entirely.
My biggest beef with the physical healthcare world is the highly virulent level of opiophobia, the stigma and judgment and distrust of ALL pain management patients, the change in tone and demeanor, the palpable shift in energy in the exam room when a patient asks a doctor if they can have "x" medication - not because they are an addict, not because they are a dealer, not because they are "seeking," not because they want party favors for this weekend's bash, but because they have researched the medication or taken the medication before, and IT WORKED.
Doctors need to STOP this reactionary behavior, these automatic assumptions, this red-flagging of patients based solely on the fact that they are either taking narcotic medication, or requesting it. At least in terms of how you think, it's time for doctors to return to the bygone era of house calls and bedside manner, as depicted in Norman Rockwell paintings, and actually
practice medicine. Screen patients. Talk to them. Find out why they want or feel they need that medication. Ask whether they've taken it before, and for how long, and for what reason. MOST OF ALL, understand that not every patient responds to the same medications, in the same doses, the same way. Someone mentioned the P450 enzymes in this thread; that's an excellent point. Not every patient is going to have the same hepatic level of CYP2D6 or 2C19. Go back to the books. There are poor metabolizers, intermediate metabolizers, and rapid or ultrarapid metabolizers.
Up to 7% of Caucasians may demonstrate ultrarapid drug metabolism because of inherited alleles with multiplicate functional CYP2D6 genes, causing an increased amount of enzyme to be expressed. Identification of UM subjects is of potential clinical importance for adjustment of doses in drug therapy, as well as to avoid misidentification of noncompliance (1). Test your patients' enzymatic levels with a simple swab. Also, take into consideration that which you learned in med school - that every patient has a different number of receptors in the brain. Some pts have less, some have more, and in those cases the patient will respond differently, often to a much lesser degree, to standard doses of narcotic medications.
Start with a 2 week script if that's what it takes to build trust and identify a particular patient's needs. Make them visit a psychologist first if that helps build trust (that might weed out a few of the dishonest ones). Then monitor the patient to the extent that you can by using UA drug screens and seeing if they call for refills early. See them again in 2 weeks and discuss the efficacy of the medication, the extent of their pain relief, how often they are using/needing the med, etc. If they are compliant, extend their script for another 2 weeks or 4 weeks. And so on. Put a little TIME into it. Be a doctor! Most of all, put a little faith into patients. Because not all of them are lying or seeking, and those that are truly in need - statistically, as many as 95% of them - are not going to abuse their pain medications.
(1)
http://www.clinchem.org/content/44/5/914.long
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