Commentary

When pain management goes right

My refusal to prescribe opioids to a drug-seeking patient led to a transformative journey—and a hug.

Sheila Ramanathan, DO
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Editor’s note: This story originally appeared in Family Doctor, a journal of the New York State Academy of Family Physicians, and has been edited for The DO. This is an opinion piece; the views expressed are the author’s own and do not necessarily represent the views of The DO or the AOA.

My eyes flitted down to the electronic medical record in front of me. I was conducting a physical assessment of a patient new to my clinic and the area. The 45-year-old male was morbidly obese and sweating profusely. I tapped away as he rattled off his various diagnoses which included: cervical radiculopathy, depression, chronic low back pain, and insulin-dependent diabetes, to name a few.

I reviewed his medication list and noticed the prescription for oxycodone. For the second time that day, I patiently explained that I would need his prior medical records, a urine drug screen, and a signed controlled substance agreement prior to prescribing any controlled substance. Expecting anger, frustration and indignation, I was instead met with ready compliance.

It was such a surprise, and it warmed my heart. My patient congenially stated that it would be fine. He had set up an initial appointment soon after moving, as he knew the snail’s pace at which the medical system runs. Knowing that medical records can take months to work through health systems, I prepared myself for the long wait for his medical chart.

With the extra time, I offered him osteopathic manipulative treatment and was able to reduce his neck and low back pain by a few points. I was ecstatic to avoid the compulsory 20-minute lecture on tolerance, escalation, and dependency on narcotics and actually spend my time focusing on pain management. I refilled his non-controlled medications and scheduled a follow-up appointment in six weeks. I also ordered a urine drug screen. I make a point of being very strict about narcotics.

A common scenario

I experience scenarios like this at least three times a day, sometimes more. I expect that it will become more frequent, especially as the number of Americans on controlled substance rises and the expectation is to be chronically maintained or escalated.

Six weeks later and no closer to obtaining medical records, my patient hastily handed me a summary note from his previous pain management clinic. It corroborated his diagnosis and verified that his medication dosage was appropriate. This clinic was in another state and I had no way to review his controlled prescription history. I couldn’t help but reflect on the ineffective regulations for statewide prescription drug monitoring, especially in areas where state lines are a mere stone’s throw away.

I looked up at him. He was sweatier than usual and clearly in pain. Since his last urine drug screen was consistent with his current medications and I had some semblance of a medical record, I refilled his last oxycodone prescription and had him plan to follow up at our local pain clinic.

Later, a nurse alerted me that a counselor at a drug rehab facility would like to speak to me concerning my patient. Startled, I picked up the phone to hear that my patient had met with a counselor to discuss his feelings of opiate addiction and suicidal ideation. He notified me that my patient had been checked into a drug rehab facility for snorting heroin in the past and was concerned he would start using again.

Horror and shame

Horrified by this realization, I felt shamed by my inappropriate prescribing. I emphatically told the counselor that I would not be prescribing my patient any further narcotics and that the remainder of his prescription would be tapered.

My heart was in my throat. How had this patient slipped through my stringent system? How had I failed to screen appropriately? The controlled substance agreement was a stack of paperwork detailing mental health, prior abuse history, and a series of agreements between the patient and myself. My patient had lied to my face and manipulated me into providing him something that could kill him. I felt betrayed.

My compassion and sense of humanity had backfired spectacularly. Dark thoughts swirled in my mind, making me wonder as to the competency of my medical training, which failed to prepare me for this. The experience led me to a state of hypervigilance and feelings of unwarranted mistrust toward my other patients.

Patient returns

Two weeks later, my patient returned to my clinic. My anger and frustration had welled up. I dread these types of visits. Visits during which I spend the majority of the time drawing a picture of the neuromuscular junction and explaining why I cannot prescribe scheduled substances to them.

My patient explained that he was in constant pain and had only snorted heroin a few times over a year ago. He demanded medication to assist with his pain control, and I calmly stated that I could only treat with neuropathic agents.

I empathized with him, and though I understood that he was in legitimate pain, I would not treat him with narcotics due to his history of abuse and the potential risks. After a 30-minute conversation, my patient walked out, muttering angrily and threatening to either go to the ER or find something off the street.

His comments only added to the overwhelming emotional fatigue that I felt about whether I was even making a difference by standing up to the wave of addiction moving through the community. I sighed with a heavy heart but mentally prepared for my next patient. I tended to be strict about illicit drug use.

‘He resolved not to’

I read through messages from my patient in the electronic medical record. After three months of waiting, he was finally placed in a rehab facility in another state. I perused the affiliated hospital records to check if he had been to our ER. He had not. I spotted a nurse’s note stating that he had successfully completed his 60-day stay and had scheduled a follow-up appointment with me.

As I walked into the small room, my patient was seated calmly. I congratulated him for completing his time in rehab. My patient smiled and relayed how he had wanted to get narcotics at the ER, just like he had threatened; however, he resolved not to do so since I had refused to give him a prescription for oxycodone. He said that his mental health had finally stabilized after extensive time in rehab and that he received the counseling help that he had needed.

After increasing his non-narcotic pain medication and completing the visit punctuated with my delighted congratulations, my patient stood up and a little sheepishly asked if he could hug me. My arms were as wide as my smile. I am strict about hugs.

Write for The DO: The DO is seeking essays and opinion pieces written by DOs, medical students and health care professionals who embrace the patient-centered philosophy of care. Learn more about how to submit here.

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12 comments

  1. Robert DeLuca

    Sheila
    This is an excellent story and a problem that faces each of us in family medicine particularly in the rural areas. The issue of pain management is a complex. We can all follow the guidelines (drug screens, multi contracts and plans, frequent visits) but still find problems. We are taught to care for our patients, leaving them in pain does not seem right but the constant worry over the scrutiny has left many older patients with chronic pain and immobility. Hopefully we can as an organization provide guidance to our members. thanks for your story

    1. Mady

      So the doctor looked out for her own interest not the patient. Like so many now. Not everyone is an addict. Take your meds as prescribed nothing bad happen to you,but if you choose to abuse them sure you ask for trouble.People make choices I choose to quit smoking .Some choose do abuse medication. And the rest of the people who really suffer with chronic pain can’t get there medicin.

    2. Sheila Ramanathan

      Thank you for your kind comments. It is a problem. At times I feel the standard of care and medical guidelines put forth seem to ignore patients in rural/low resource settings. Often we are the only advocate for our patients who have complex medical and socioeconomic issues that few understand fully but only we as primary care can appreciate as we offer comprehensive care to entire families. Thank you again for your response.

  2. D Rosser

    Sheila, did you ever wonder why he had resorted to snorting heroin? Many prescribers fail to realize the many complications and efforts chronic pain sufferers go through to stay on that narrow line they are left with after their diagnosis. With the social stigma and self righteous prescribers like yourself misreading and misjudging the situation as common as a move from another state which may have been beyond his control. It leaves so many sufferers stuck as well as mortified for having to add this to the myriad of issues that trip us up everyday. My precriber whom I have been working with for 7 yrs listens and works with me. She’s doing the job of keeping me on my feet as well as giving me a good quality of life. As I age, with my degenerative conditions she trys as many different therapies available to me but we build on top of my narcotic use not abuse. Yes,precaution is great but single minded distrust of your patients could be considered abuse. Keep your mind open despite sensational journalism and skewed doctors polls ect.

  3. Jenna

    Good point of reference. Many patients are in pain, severe pain. They are not this man and aren’t looking to pull one over on you.
    Hopefully he didn’t cause you to be too hypervigilant and feel that all pain patients asking for narcotic relief are secretly snorting heroin.

  4. Jennifer Thompson

    I was on Percocet 10 4 times a day and my Dr? Decided to stop cold. I was also on soma and Ativan 3mg a day dea flagged my account. Guess what I was not addicted. I stopped cold two years ago. I am in serious pain but I would rather die than go through being treated like a criminal by the medical profession again. I at one point had a supply of extra strength Vicodin 380 pills. I never took more. But I have to be a criminal by the medical profession. 17 years of pain management all I want is to be treated for my pain. I actually have troubles breathing if I walk. Pain Mngmt clinic in Michigan stared I had probably 1 of the 5 worse backs they had seen I have had 7 back surgeries and none of my surgeries was robotic.

  5. Robert Gomez

    After being hit head on by a drunk driver 98 and fallIng off a ladder at work 2017 and WC denied my case through nefarious reporting by my employer I’ve been continuously losing use of neck and entire left side, whilst being in constant 8 level pain which feels like nonstop cigarettes needles and occasionally a chefs knife to the handle in the neck and shoulders spiking to unlivable pain spikes. I also have chronic kidney stones passing 6&7mm stones at least once a year, which do mimic my pain spikes. After taking lyrica, cymbalta and 3 other meds for neuropathy and MS . I finally found 30% relief with Peracet and a rotation of muscle relaxers sleep aids and anti-inflammatory are the only things that get me out of bed with some topical special made from my pharmacy. Recently my pain management are being pressured and threatened to the point of chancing the inevitable back to hell route because of idiots partying with what’s saving my life . Before we compromised to the dose and amount, I was in bed 20hr daily in too much pain to use a toilet proper shop or do laundry. I’ve lost everything, and friends and family are dealing with their own situations. These seekers are going to kill people inadvertently by what their doing . But obviously we are left to suffer for guilty parents who want to point the blame anyone but themselves. Pushing those who live and breathe because of responsibile opioid use. No one stands up for us, it’s all about them. Wish we got some press

  6. Erica

    Please just never forget there are legitimate patients who truly do everything right. In my own case I gave learned to keep copies of most (not all, I have an extensive history with a very complex genetic disorder) of my medical and surgical records due fron my genetic disorder this avoiding delays if I ever did move. Here in my state we also have Epic/Care everywhere so my drs at 4 different health systems can see each others notes. Still not perfect but for us pts with chronic pain who are doing everything right. Seeing our PM Drs every mo, seeing PT, PMR (botox for spasticity and dystonia) and have mever needed to increase our med doses (despite in my case to date almost 70 surgeries due to my genetic disorder) we are doing what we can. I appreciate you seem tomaybe still prescribe for some of your pts but I just ask don’t let 1 or a few harder cases make all pts with pain seem like they will fail you. Most won’t

  7. Hank Hill

    Pain management doctor’s think they no what to do and how to help but they really have no clue on how much pain someone is in they hurt more then help they stop pain meds and people suffer if you really have a certain pain like pancreatitis that person needs meds not aspirin I wish the pain management system could get a clue on what to do

  8. Bruce Fosdyck

    Sheila, you are so correct. It seems that in the fury of trying to stop all the prescriptions of opioids, the medical field has forgotten about those who are with chronic pain with no chance of recovery. My spouse is an example. After 2 botched back surgeries and a 3rd one to stabilize her temporarily. She has been cut back to the point where she is in constant pain once again. She was on a regimen at one time where she could almost carry on a regular life of activity. Once the so called opioid epidemic took off, she paid the price for others stupidity and negligence. I am so angry that in the year 2019 we as a whole can be so ignorant as to what should be done here. Some people obide by their prescription and it works for them. Why mess their lives up do to others who are fools. Sorry but I worry for her daily

  9. Tom Horvatin

    Doctors are reacting too aggressively to the first CDC mandate regarding Opioids and patients but not aggressively enough to CDC follow up memo that in some cases Opioid treatment properly given and managed can really help a patient return to a normal life.

  10. Xavier Cavanaugh

    As a chronic pain sufferer, and as I use a pain management doctor and have been using that Doctor
    for decade, and the
    opioids that I am prescribed are used correctly and patience& We should not be condemned or scrutinized by the people misuse them…

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