Patients Who 'Must Have' Pain Medicine NOW

Michael J. Schiesser, MD


March 25, 2015

In This Article

An Effective Way to Deal With 'Problem Pain Patients'

Physicians who manage chronic pain patients with opioids often meet pushback or resistance when talking about drug risks with their patients, who often feel those risks don't pertain to them. Sometimes patients with pain behave erratically or emotionally, and their aberrant behavior puts doctors into the awkward position of making a judgment call, and perhaps providing arbitrary or inconsistent care. I can suggest a better way.

The Scope of the Problem

As an internist and addiction specialist, I regularly give advice to clinical leaders in primary care who are struggling with challenging patient behaviors related to potential medication abuse.

On behalf of the leadership of one clinic that asked for my help, I recently performed one-on-one, face-to-face private interviews with a dozen physicians at a small primary care clinic. What I found was relatively similar to other clinics where I have performed similar work, regardless of size.

The physicians' perception of their panel size of patients managed with chronic opioids was generally smaller than the electronic health record data indicated. Also, many physicians were very eager to discuss at least one "problem patient" with me, looking for guidance and support.

All physicians were eager to express complaints about other clinicians in the clinic, and many confessed that it was awkward to discuss these issues directly. The smaller a physician's opioid panel, the more they complained about the doctors with a large chronic opioid panel. Complaints revolved around how to deal with unexpected patient issues that arose while on call, and concerns about care they felt was unsafe, stating they "didn't want anything to do with it."

Conversely, the doctors who managed many patients, and with larger dosages, complained that physicians with smaller panels "didn't know what they were doing." They also felt that there was insufficient patient management during on-call coverage. For example, on return from holiday, they discovered the on-call physicians had "only given the patient enough medication until I get back, then the patient complains they didn't get their usual monthly refill."

It's common to externalize this phenomenon as if we play no role in it, and characterize it as "problem patients" or "pain patients." This is generally a weak perspective, especially when the variation in care among providers from group to group, county to county, or state to state is considered.

For example, in Virginia, physicians write 78 opioid prescriptions for every 100 persons, per year. That number almost doubles to 138 prescriptions per 100 people way over there in West Virginia.[1] Clearly, these variations are not evidence-based, and instead are more cultural in nature. Within any given clinic, I see even more profound differences from one provider to the next, with no shortage of reasons why.


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