Compassion vs. Reason

[Guest guest]

Given that one in five of all patient visits is to address chronic pain issues and over 40 million Americans suffer from chronic pain, it is neither reasonable nor desirable for primary care physicians to choose to not address this important issue. Bill McCarberg, of Kaiser Permanente Southern California, one of the preeminent pain specialists in America is currently arguing that primary care physicians are the logical providers to address chronic pain because we know the patient, the family and are able to address the frequent psychiatric issues which accompany chronic pain. Pain management is a specialty, but most parts of the United States are profoundly under served. Yes, both federal and state agencies are policing physicians who manage pain. Mistakes in prescribing are not an uncommon reason for getting into trouble with medical boards. There are widely

accepted guidelines for managing chronic pain and I fear these guidelines are not being followedI consult the Rhode Island Board of Medical Licensure and Discipline reviewing the opioid prescribing patterns of primary care physicians. Several aspects of this case concern me. I like the signed controlled substance agreement ( I eschew narcotics only agreements insisting that patients taking benzodiazepines and stimulants also sign). I trust the contract includes essential clauses related to the safe storage of medications and clear understanding that lost or stolen medications will not be replaced. The medications in this case were unsecured repeatedly- a serious violation of any controlled substance agreement. To replace once is compassionate and reasonable, but to refill after a second episode of the daughter stealing medications, particularly after explicitly agreeing that the daughter must not return to the household, is unwise and putting

the prescriber at risk. Even considering a third refill is unwise. Medical Boards frown on compassion trumping reason. Do not put your ability to prescribe controlled substances in jeopardy. If you have rules, you and the patient must abide by them. Several details were omitted. Refills of all controlled substances should only be written at a patient visit. Do not call in refills for lost controlled substances. Perform a urine drug screen at the visit to insure patients are taking the medications you prescribe. Withdrawal is extremely unpleasant, but not life threatening. I would consult my State Board of Pharmacy and/or Medicine seeking guidance as to how to handle the situation. Make a referral to a pain specialist, even if not readily available.