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A Risk to Whom?

If you haven’t received the letter yet, it is in the mail. At least it will be if you are serious about providing good patient care.

The intent of the letter is to intimidate. To threaten. And it works. Providers change their practice, blindly accepting the judgment, from someone they’ve never met, that they were doing something wrong. A judgment made by one far removed from the exam room, one isolated from the repercussions, someone who could never do your job.

Still the letters pour in. From the Prescription Drug Monitoring Program Advisory Commission Prescribing Practice Review Subcommittee, an eternally long title with no person’s name attached. From UHA or OHA. From the Oregon Medical Board. From the pharmacy. Signed by the entity, almost never a person, but emitting a feeling of virtue, as some aspect of your pain management is condemned. By providing prescriptions of excessive morphine equivalents or combining opiates and benzodiazepines, you are placing patients at risk of unintentional overdose and death.

Occasionally it is true. Usually, it isn’t. After 45 years of practicing in Roseburg, I am not aware of a single case of accidental overdose or death in our combined Evergreen practice resulting from using these controlled substances as they were prescribed. And we have treated tens of thousands of these patients.

I have seen deaths from intentional overdoses, usually a combination of illicit drugs and alcohol, but also including a mixture of prescription drugs. Earlier in my career, many of these involved amitriptyline, an antidepressant. And I have seen suicides due to unresolved pain. We’re beginning to see more of these.

I recently witnessed a discussion between two veteran family physicians as they spoke of cases and conversations with patients. I thought their insight was thoughtful and provocative.

“A patient told me that before the enlightenment, he was a functioning individual. He was working. ‘Now I’m suicidal. Life is hell. I have no plans to follow through (with suicide), but if a car was coming at me, I wouldn’t move out of the way. This life isn’t worth living.’”

“What do I say to that patient?” the physician asked. “UHA is happy because we reduced his morphine equivalents. But they’re not in the room. I am, and I don’t have a good answer for him.”

“My patient was on hospice. They started her on a Fentanyl patch and some benzos. But she hasn’t died yet, so she was discharged back to my care. She is still as sick as she was before. She hurts just as much. But now I’m getting letters, from the same pharmacy filling her prescriptions all along, stating I’m putting her at risk because I’ve continued the medications initiated under hospice. Am I supposed to require this elderly lady to be miserable until she qualifies for hospice again?”

“With any other medication, I can have an informed consent conversation with the patient and their family, and that is enough. Anticoagulation, antiarrhythmics, chemotherapy drugs – all place the patient at risk. The question is whether the benefit they receive is sufficient to warrant that risk. But with pain management, I have that same agreement with the patient, and am still second guessed by someone not in the room, not party to the conversation, and who never lives with the consequences.”

“I have a man with debilitating headaches. He has benign brain tumors creating the pain. If these were malignant, no one would question my care. Because they are benign, yet inoperable, my care is questioned. He came to Evergreen on very high doses of opiates initiated by pain specialists at OHSU. We have decreased dosage considerably, but he still exceeds 90 morphine equivalents. He has been treated with high dose opiates for 40 years without adverse incident. And he’s at risk? Of what? Now, he’s on a much-reduced dose of opiates and his quality of life is terrible. His risk is that of suicide. This is what success looks like?”

“I’ve had two patients who have committed suicide in the last couple years because of undertreated pain. We were tapering their narcotics according to CDC guidelines. Their care looked good on paper.”

“A patient told me that ‘I was happy before. My mood was better when I was on pain medication. Now, I’m off the medication and just surviving. I think about suicide a lot.’ The truth is opiates, in addition to alleviation of pain, do impact mood in some patients.”

“One of my patients was frank. ‘Doc, I just get it on the street. It’s a lot easier and I can get what I need’”

“Another patient has already undergone 2 surgeries on his back, both of which left his back pain much worse than before. Now, he has severe osteoarthritis in his knees. He is only 63. He should have total knee replacement, but he refuses surgery. He tells me he trusted the doctor twice before and it didn’t work out. “I’m not having any more surgery”. What can I say to him? I understands how he feels, even if I think he is wrong.”

“What is the greater risk?” asked the man in our chronic pain management group. “Taking a few hydrocodone daily or having back surgery?”

“My 70-year-old lady has the combination of systemic lupus, rheumatoid arthritis, and severe osteoporosis. She has multiple compression fractures and both cervical and lumbar myelopathy. She is not a surgical candidate. She is extremely anxious. She always has been. So, in addition to antidepressants, she is on a benzodiazepine and opiates. Of course, I got the letter. They see the prescriptions. They don’t see this lady. Yet, they assume they know better than I how to treat her.”

I wish the oversight authorities would visit Evergreen’s pain management group. They would see 75 – 100 patients with an average age about 70. I don’t think there is an addict in the room. Just a lot of folks with chronic pain trying to get by.

Primary care is hard work. Complex entanglements of life events, pathology and mental health factors do not lend themselves to easy answers. Much discernment and nuance are involved. There clearly exists limits in effectiveness of opiates in alleviating pain. Combining antianxiety agents or muscle relaxants with opiates does create potential risks. Yet, there are circumstances where these interventions are helpful and necessary. Who should decide that? Hard guidelines of morphine equivalents and combinations of opiates with minor tranquilizers would be acceptable - if they were truly guidelines left to the discretion of the provider charged with helping that patient negotiate life.

There is a thin line between mental illness and pain. How each impact the other’s expression is well understood by the experienced primary care provider. Similarly, medications used to treat one condition impacts the other. Thoughtful informed decisions in the exam room should not be second guessed by administrative authorities who weren’t there and don’t live with the results of those decisions.

There is no data to establish an increased risk of death when exceeding 50 morphine equivalents in our controlled population. At Evergreen, we monitor patients carefully with urine drug tests, every 3-month visits, checking PDMP, adhering to protocols, and utilizing a chronic pain management support group. We have an active SUDS group and an internal chronic pain management consultant service.

Although the CDC states their clinical practice guidelines are to provide recommendations only, and that it does not replace clinical judgment and individualized patient centered decision making – this is clearly not how those recommendations are enforced by heavy handed agencies who believe they are reducing risk. Risk to whom? Not to this patient population. And the risk to ethical providers is increased.

Evergreen is starting a palliative care program. CDC specifies that Palliative Care is excepted from their clinical practice guidelines. I hope that designation will allow our providers to do what is best for the patient in front of them. This is where heart of medicine should live.

Tim Powell MD

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