Can You Hear Me Now?

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As the Project Director of the PAINS Project, I talk almost daily with someone with a question about how to communicate with their healthcare provider about their needs, how to handle the stresses of daily life and work combined with chronic pain, how to find the courage and determination to press forward one more day. Chronic pain is a relentless taskmaster. 
 
For example, one person called because their longtime doctor told them they could no longer prescribe opioids for their pain and referred them to a pain management clinic – even though they’ve been on the same dose for more than five years and never had a problem. The pain management clinic gave them a three-week prescription (21 days) but scheduled their next appointment 25 days out. That means this person has to choose: 

  • Do they take their medicine as prescribed, meaning they will be out of medication before the next appointment? 
OR 
  • Do they stretch the 21-day supply so that it will last the full 25 days, thereby running the risk of unmanaged pain? 

How do you decide? Why is this happening?
 
There are many reasons that the treatment of pain is controversial and under-treatment is so prevalent. As outlined in the February 2009 Policy Brief, Balance, Uniformity and Fairness:  Effective Strategies for Law Enforcement for Investigating and Prosecuting the Diversion of Prescription Pain Medications While Protecting Appropriate Medical Practice:

The under-treatment of pain is due in part to a kind of undesirable “chilling effect.” The concept of a chilling effect, generally, is a useful law enforcement tool. When publicity surrounding a righteous prosecution “chills” related criminal conduct, that chilling effect is intended, appropriate, and a public good. A chilling effect on the appropriate use of pain medicine, however, is not a public good. Recent research by members of the Law Enforcement Roundtable confirms that prosecutions of doctors for diversion of prescription drugs are rare. But, on occasion, overly-sensationalized stories of investigation of doctors have hit the nightly news. When that happens, the resulting chilling effect reaches far beyond a “good” chilling effect on bad actors, and directly affects appropriate medical practice. The consequence is extreme, and not what law enforcement would ever seek – our parents and other loved ones who are in pain simply cannot get the medicines they need.

Another potentially chilling effect is the recently released CDC Opioid Prescribing Guideline. The 52-page report includes 12 recommendations to primary care clinicians about the appropriate prescribing of opioids to improve pain management and patient safety. They are indeed recommendations, but the chilling response by many providers is to see them as THE standard of care and choose to simply cease prescribing opioids, refer patients to pain management clinics, or simply show them the door. 
 
So what is a fitting response to the person asking for guidance on communicating with the pain management clinic about their need for 25 days of medication when there are 25 days between appointments and prescriptions? 
 
There is no good answer, but I believe communication is key. My recommendation was for the patient to be as kind as possible to himself, use affirmative self-talk, and to employ every complementary and alternative method he had learned in his decades-long journey with pain. These may seem like insipid platitudes, but we’ve learned the value of self-care and self-compassion from sages through the years. 
 
Additionally, I suggested that he “seek first to understand” when talking with the provider. Providers may feel they have regulators breathing down their necks, and many physicians have been questioned about their completely appropriate opioid prescribing practices. It is not unreasonable for a provider to be concerned, especially when their practice can be totally shuttered by an investigation even though no indiscretion is ultimately found. 
 
An open, honest conversation between the patient and provider about their respective fears and assumptions can play a significant role in pain management. 
 
What are your recommendations? How would you respond to these questions? Let us know in the comments below. 


Cindy Leyland is ProHealth's Fibromyalgia Editor.  Cindy also serves as the Director of Program Operations at the Center for Practical Bioethics and the PAINS Project Director. She lives in Kansas City with her husband, enjoys hiking, reading, volunteering with Synergy Services and being Gramma Cindy.

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