I don't know if it's the hot weather, or what, but the drug-seekers are out in force right now.

[Aristus]

A few weeks ago, I treated a patient for a persistent cough. She's a heavy smoker, but like a lot of smokers, she denies that there was any connection between the two. She did have a mild upper respiratory infection, so I treated her for that and gave her something for the cough.

She's been back in day after day since demanding codeine for her cough, instead of the perfectly appropriate, effective anti-tussive I prescribed for her. As with many other patients, her explanation is "It's the only thing that works!"

Yesterday, I had two of them. One guy said he woke up yesterday morning with the 'worst pain ever' in his left lower back. I examined him, and sure enough, he was spasming pretty badly in the lower lumbar region. I prescribed him a muscle relaxer and a non-steroidal, and advised ice-pack treatment until the symptoms resolved. He got very angry and demanded "Something stronger! Something that works!" When I told him that this was the appropriate treatment, and conformed to standard-of-care, he pulled out a not-uncommon trick of the trade: "Well, I guess I'll just have to go out on the street to get it!" He wasn't happy when he left.

The second guy was less up-front about his desired analgesic treatment, but I had to let him down gently, and prescribed the appropriate treatment.

Thank you for listening. I love you all.

If I posted this in GD, I would be descended on and devoured like a swarm of locusts by a mob of screamers calling me a torturer, a sadist, and a bad medical provider for not giving my patients what they wanted...

[Fla Dem]

1. If only more medical professionals practiced this approach.

[Bradshaw3]

2. Sounds to me like you are being responsible

In my apartment building a woman has back issues and was going to the hospital every 2-3 weeks after her prescription ran out, saying "pain, pain" over and over to the EMTs cuz she wanted more drugs than prescribed. She finally has started cleaning up her act and it turns out her condition is not as bad as she made out. She wanted the opiods because she was addicted. The answer is not to enable their addiction but to get them off of them. Good for you.

[Moostache]

3. Responsible and ethical practice of medicine? In 2018 America?

THANK YOU!

Doctors across the country need to show the same spine as you have. Don't give up the fight to help people ethically and to inform them of the dangers of them deciding treatments, what with their OBVIOUS Medical Training and YEARS of Expertise and all....

[Canoe52]

4. I have a friend in the medical field and this is her

number one complaint also.

[hlthe2b]

5. I follow the European medical literature pretty heavily...

Americans would be shocked at how few surgical & dental procedures receive anything other than NSAIDs post-op. That includes knee replacements and other ortho procedures. AND, their outcomes are comparable or in many cases BETTER than ours.

Back surgery is a last resort, not a first and NSAIDs, rest, muscle relaxants, physical therapy, acupuncture form the more comprehensive course of care.

So, you will get no arguments from me.

I will forever argue that end of life care should get a pass for whatever opiates and whatever doses seem to make pain bearable and in some cases, chronic intractable pain may need to be considered for long term opiate exceptions until we can find better alternatives. In general, though, no.

[Aristus]

7. That's true.

I keep a reference manual "Responsible Opioid Prescribing" on my office bookshelf, and it is very clear about end-of-life care. That's when all considerations regarding addiction (obviously), tolerance, and respiratory depression go out the window, and the one overriding goal is the comfort of the patient.

My father got appropriate palliative care when he was dying of pancreatic cancer, and I'm very grateful that he did. There's a time and a place for it.

[Shrike47]

32. I would love to be able to take NSAIDS but my cardiologist says no.

[hlthe2b]

34. Does he/she have you on low dose aspirin? If so, that is an NSAID

There are concerns across the group for GI inflammation, especially on higher doses.

There are likewise concerns re: increased risk for heart attacks and stroke which includes the group of NSAIDs that includes ibuprofen (Motrin, Advil) and naproxen (Aleve). Celecoxib (Celebrex), diclofenac (Cataflam, Voltaren) and other prescription only newer drugs. Aspirin, while an NSAID is not included in this group linked to higher cardiovascular risk, but obviously still has issues with GI inflammation. The increased risk of CVD is low, but real. Of the NSAIDs potentially linked to higher CV risk, naproxen is considered to have the lowest risk for those who do not have a sensitivity to it.

It would be good for you to have a detailed discussion with your cardiologist as to how best to treat musculoskeletal pain. Good idea for everyone, frankly, in light of these recent studies.

Still, when one looks at the risk-benefits for NSAIDs over the horrific impacts of chronic opiate use with what appears to be irreversible neurologic impacts (e.g., "rewiring of neuronal pathways resulting in both addiction and damage) in chronic use, the slightly increased risk of CVD in some patients or gastric bleeding at high doses in others appears to favor NSAIDs as a first line for pain. Certainly for acute pain in the majority of post-op settings.

[TubbersUK]

6. Out of interest

How would you respond to this hypothetical patient (well actually my Dad):

81 years old
crumbling/crumbled spine
in severe and constant pain
rapidly losing quality of life due to pain
rapidly losing mobility due, among other factors, to pain

[Aristus]

9. First, I'd make sure he got the appropriate analgesic for his pain.

Opioids are a possibility, unless he has moderate-to-severe lung disease. Then a consult on palliative care. If palliative care is not an appropriate option, then I would refer him to pain management.

Cases like these are the ones in which some form of opioid therapy is considered appropriate.

The hypothetical patients I get too often:

20 years old.
In no visible distress.
Blood pressure, heart rate, and respiration all within normal limits.
No significant past medical history.
A request for Percocet because "I've got 10/10 pain, and Percocet is the only thing that works."

People who get upset when they hear that patients are being denied opioids rarely bother to draw a distinction between such patients, and patients like your father.

[TubbersUK]

10. Thanks very much

Useful information.

[Aristus]

12. My pleasure.

[CanSocDem]

11. Good question.

This is the problem with 'Modern Medicine'. As we are seeing with the good doctor, too often medical treatment is less about the needs of the patient and more about the mood of the practitioner.

My late father was in the same situation and spent the last weeks of his life in a bed, immobilized by drugs and pain. If I had the courage of my convictions, I would have propped him up in front of a large screen in his favorite chair and given him all the Flight Simulator games I could find. He loved flying...

Instead, the modern medical response to his condition was to suppress, pharmacuetical-ly, the pain, despite its' effect on mobility.




.

[malthaussen]

8. Keep your standards.

I believe one of the first requirements of the Hippocratic Oath is "first, do no harm." Which is, admittedly, a fraught requirement, but over-medicating or prescribing the wrong medication would seem to be a mark of gross incompetence, or negligence.

How do you deal with the patients who come to you with one arm hanging on by a ligament and insist it's "nothing?" There are those who would rather die than "make a fuss." Literally.

-- Mal

[Staph]

13. I had a hysterectomy five years ago.

The first night, the nurses kept telling me to press the button for a dose of morphine, that it would help me sleep. I told them that I would be able to sleep if they didn't come in hourly to check on me and take my vitals. I finally had to press the button to make them shut up and go away. I never pressed it again. I was fine on Tylenol.

I personally hate opioids. The constipation is awful!

[Aristus]

14. The real fun is when they wake you up in order to give you a sedative.

There are some nurses out there who should really try another profession. But the vast majority of them, I have tremendous respect for.

[LuckyCharms]

15. After my procedure yesterday...

The surgeon asked me if I had a preference for what I wanted for pain.

I told him I didn't need anything.

He looked at me like I had 3 heads and said...why not?

I said I had a bottle of them at home. I have them for back pain and take maybe one or 2 pills a week (ie: I took 2 yesterday) when I can't stand the pain anymore. It will take the edge off just enough for a few hours.

He asked me if I was sure and I said yes, I'll be ok.

The way I look at it is this...if I start asking for pain killers when I can get by without them, I may not be able to get them if the occasion arises when I REALLY need a new script.

[Major Nikon]

16. You are a torturer and a sadist!

Honestly though I think we need revolutionary changes to our drug policies in this country. I think virtually all drugs should be legally available one way or another. Those that are less dangerous than aspirin should be available OTC. Those that are more dangerous than aspirin should be available with a prescription regardless of the medical necessity. It's far better for those that take them to be under a doctor's supervision than without.

Our national drug policy isn't reducing the number of users, it's just forcing them down paths that are a detriment not just to themselves, but for all of society.

[hibbing]

17. Can you prescribe me some weed and have it delivered?

[Aristus]

18. I read your other post about not wanting to drive 500 miles for cannabis.

Unfortunately, I'm not licensed to prescribe it. It's available over-the-counter here in Washington State anyway.

[hibbing]

19. Never hurts to ask...hehe

[RobinA]

20. It's A Dilemma

I had a back glitch a month ago. Pain 10/10 when it seized. It did settle down a little so I could sorta function. Went to the doctor to see if she could come up with something that was better and safer than the 800mg of Aleve that I was taking at a pop that wasn’t working all that well. I neither wanted nor expected anything stronger. She made me cut down on the Aleve and gave me a muscle relaxant. It may be the standard of care, but who’s kidding who, it doesn’t work much.

Luckily I have a high pain threshold and could fudge at work when I had to stand for long. I did get a PT script out of the deal which thankfully did work.

I feel sorry for people with more pain or who are less pain tolerant. In today’s world they are SOL.

[Phentex]

21. This may be in my head but cryotherapy has done wonders for me...

Not only do I just flat out enjoy the freezing cold feeling, I no longer have joint pain. Or back pain. The biggest difference is in my knees and ankles though. I am able to walk miles every single day whereas before I had to skip days.

It's not for everyone but it's been amazing for me. I guess you could say it's like your ice pack treatment but without the packs.

[smirkymonkey]

22. What is that? It sounds like something I would be interested in.

I am violently allergic to opiates, so I relied on ice packs for the pain when I broke my upper arm a few years ago and they really helped, but I could only use them when I was lying down. I was in excruciating pain - the worst ever, but I couldn't take any pills. I am always worried if something happens again that I will be out of luck because I can't handle opiates.

[Phentex]

36. I do whole body cryo where you step into a chamber

and they use nitrogen gas to lower your body temperature eventually to about 30 degrees. You only get 3 minutes. I am not sensitive to the cold at all so it never feels long enough!

Many athletes use it for recovery but some people use it prior to a workout for better results. I do not buy all the hype regarding the other various benefits they claim from this therapy but I do think it works like cold packs or ice baths without all the mess.

And I discovered this place treats the membership like a gym membership. You can bargain your way down to a price you are comfortable with. I've seen places that charge $50 per visit! I think it's worth it but I could never pay that. I had a coupon to start for 6 visits and then I talked them into a monthly membership of unlimited visits. Then I scaled back to two times per week and it's less than what I'd pay to go to one movie.

Also, the owner is very health conscious so I bet she'd be willing to work with anyone who had a medical need. I was skeptical but the proof has been in the lack of knee/ankle and back pain.

I also like to stand in the refrigerated section at Costco. Temp is kept at 40 degrees. I stand in there and make my lists.

[smirkymonkey]

38. Very interesting. Thanks for sharing that.

I am not at the point where I have chronic pain yet. Mostly low back and upper back/neck pain from being at a computer all day, but I use lidocaine or Salon Pas patches when the pain flares up. I go through phases with it. I will have to look into this. Thanks!

[steve2470]

23. As always, I'm glad to see you hold fast to appropriate practices

My family practice doctor has the same problem: people come in demanding or manipulating for opiates. He won't give them but I think he will refer his patients in great pain to a pain specialist. Luckily I've never needed that service.

Keep up the good work

[zanana1]

24. The problem is, when somebody does require an opiate for pain,

they can't get it. I've never had a strong opiate for pain, but if I did need one, I'd be afraid to ask for one.

[Kaleva]

25. A big problem where I live is people selling their prescription pills.

[Aristus]

26. Selling the pills, selling the prescription, we have to be on the lookout for people doing either.

A lot of my patients are homeless, and many times, they'll come in for an early refill of their diabetes medications, or high blood pressure, high cholesterol, thyroid, etc. because someone stole their medications looking for opioids.

I tell my patients to keep their medications on their person at all times, because drug-seekers won't bother to read the labels of the bottles they're stealing to check for anything of street value; they'll just grab first and look later. When they find nothing of value, they won't return the medications to my patients, of course.

Opioid prescription and management is fraught with all sorts of risks for the medical provider. But that rarely matters to a Percocet enthusiast who simply grumbles: "Why can't you just give me what I need?"

[Kaleva]

31. A family member once stole my dog's Tramadol.

Thankfully, a year in jail for other crimes and counseling broke him of his drug addiction.

[Shrike47]

33. I used to leave my hydrocodone in my suitcase on business trips. I learned the hard way.

[Crutchez_CuiBono]

27. In Canada you can purchase Tylenol(?) w codeine over the counter.

It can be used responsibly. But anyone who has impulse control issues should be in therapy, not drug seeking. MJ should be legal now. Everyone who seeks these drugs would have a legal alternative and get what they need from a few puffs. The worst that happens if you smoke to much MJ is you eat everything in the refrig and crash on the couch w a quart of ice cream. No ones dies, and generally folks can say no to it, unlike the upper tier pain meds.(USUALLY...for those who like to nit pick.)
I remember getting my molars out, the dr gave me Tylox, I'll never forget it. I FELT like going back, but, if you are wise, you know when you're standing on the precipice. People feel hopeless nowadays, and they just don't care.
Very few people under 30 have backs so bad they require continuous pain meds like that. Go to the gym.

[janterry]

29. Go to the gym.

is the best advice ever

[janterry]

28. I've spent most of my career as a MSW

so, med seeking is a given (and, I must say, it's given).

I understand, personally, that pain is so scary - so I sympathize - though I've never been on codeine or anything really strong. But I had a close family member prescribed Percocet and Valium for decades.

(This, despite his 'really important' diagnosis - that they interestingly missed: alcoholism. So, let's just say --he had a hard life

[MontanaMama]

30. Stick to your principles.

I appreciate a medical provider who talks about the standard of care and will suggest treatments that aren’t pain med prescriptions. We try to use ice/heat, ibuprofen, essential oils/massage and a TENS unit in this house before we reach for anything stronger. My kiddo will often ask “Mama, can you oil me up?”

Had my 13 year old at the Dr a little over a week ago. High fever for 4 days that I could control with ibuprofen but that would spike as it wore off, body aches, sore throat. On day 4 he began vomiting and had the beginnings of a cough. I saw a lesion in this throat and thought he had strep for sure. Took him in and the strep test was negative. The doc came in and said he was seeing a nasty virus with fever lasting 5-7 days. He offered magic mouthwash for the sore throat but other than that, he prescribed rest and lots of fluids. My son declined the mouthwash rx in favor of slippery elm tea and manuka honey. His fever is gone but he is on day 8 of the cough that isn’t resolving. I’ll take him in today to let the doc see him because I don’t feel like his cough is getting better....not sure if there’s anything to be done for it but I appreciate a professional that’ll tell me how it is, even if it’s not what I want to hear. Sometimes we just have to get through stuff.

Stay strong Aristus. 👍🏽

[blueinredohio]

35. When I go to the doctor for whatever is bothering me

I don't want pain pills, I want the doctor to fix it so I can get back to normal.

[Aristus]

37. That's the cornerstone of my practice: treat the underlying cause,

not just the symptom.

The treatment of musculoskeletal issues is almost always multifactorial, involving oral and/or topical medications, home exercises, physical therapy, therapeutic massage, joint injections, and even surgery. But we live in an era in which people want to pop a pill and be done with it, rather than engage in the effort of a multipronged approach like the one described above.

I respect your desire to have the causative issues addressed, rather than masked.