Jennifer Adams, MD
Note: Patient name and some details of the case have been changed to protect confidentiality.
Acknowledgment: The author thanks Ingrid Binswanger, MD, MPH, and John Steiner, MD, for their help with preparation of the manuscript.
Requests for Single Reprints: Jennifer Adams, MD, Denver Health and Hospital Authority, 1100 Federal Boulevard, MC 3000, Denver, CO 80204; e-mail, firstname.lastname@example.org.
Adams J.; A Balancing Act. Ann Intern Med. 2012;157:215-216. doi: 10.7326/0003-4819-157-3-201208070-00015
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Published: Ann Intern Med. 2012;157(3):215-216.
Nicole appeared on my primary care schedule the first week of every month. She was 29 years old when she began seeing me for management of migraine headaches, uncontrolled type 1 diabetes, chronic renal insufficiency, and major depression. She was unemployed, was without stable housing, and was a single mother of 3 children. She had been prescribed low-dose oxycodone 6 years prior to use only for severe refractory headaches. Over the years, we slowly increased her daily dose as she reported uncontrolled migraine pain. I told her numerous times that I thought opioids were inappropriate treatment for migraines, but alternative approaches to pain management were ineffective. At nearly every visit, she requested an increase in the number of pain pills she was prescribed and believed that I was not listening and did not care about her when I was reluctant to increase her dose. I was frustrated by my inability to effectively treat her headaches and believed that our time together would be better spent addressing her other medical issues. Although I wanted to treat her pain, I was worried that I was complicit in the development of an opioid addiction. This was not the kind of medicine I wanted to practice.
Neil A Louwrens, MD FACP
Mercy Medical Center Redding
August 25, 2012
Acting to the Unbalanced
Each of us involved in the compassionate and evidence based care of our patients with pain would agree with her statement that ‘this was not the kind of medicine I wanted to practice’. Her report of ‘burn out’ related to the frequency of such patient encounters certainly comes as no surprise. Pain is unfortunately a common problem in our society and little else summons the ‘healer’ more urgently to action than these patients in distress. Harkening this cry, and responding to our ethical obligation, whilst striving ‘to comfort always’, we heed the higher calling to deliver relief. And what a glorious relief these opiates bring. But the constant strategically calculated bombardment for requests of opiates by a growing number of dependents is overwhelming. It is unbelievably draining and perhaps one of the single most significant contributors to compassion fatigue. Unless our profession strategizes a meaningful intervention to this pervasive ill, provider satisfaction will likely continue to fail. Unfortunately industry sponsored ‘education’ on pain management, and a somewhat misguided government-sponsored focus on ‘Quality’, the backbone of value based purchasing, is calling us to satisfy the health care ‘consumer’ (aka patient) at all costs! Professional objective judgment, despite serving our profession soundly for thousands of years, has been relegated to voodoo medicine. We all know that to ‘opiate dependants’ (aka addict) the only ‘valuable’ care worthy of receiving a ‘high’ quality score is a substantial narcotic refill. Nothing else really matters, and certainly NOT the quality of your care! And, as my colleague so poignantly points out, there is ‘no objective decision aid, instrument, or measure’ that assists us on this slippery slope. And the crude ‘fifth vital sign’ is at the heart of this issue is it not? In the setting of opiate dependency a more crude, inaccurate, non-objective and easily manipulated tool you will be hard pressed to find in all of modern society, save for the ‘Disability’ and ‘Workers Compensation’ arenas. And we all know the magnitude of these abuses, yet few have the time or political fortitude to make a stand and enact change. Colleagues, it would be wise for us, as hard as it is, to report the suspected abuses more widely. Our silence and unwillingness to call out such observed patterns are doing a disservice to our colleagues, and to our profession, but ironically most importantly by those who perpetrate these injustices. These dependent patients would be better served by a profession calling things out just as they are, and medico-legal, quality and regulatory systems responsive to our observations.
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