Narcotics

Dixie asked me to give a post about narcotics.  This has been a very frustrating subject for me in the last couple of months because I walked into a practice where the physicians were much more liberal with the narcotics than I believe is best for the patients.  The first week I was here I prescribed more narcotics than I had the entire time I was in Wisconsin.  It was ridiculous.  I should make the distinction between short-term narcotic use and chronic use.  Short-term use for broken bones, medical conditions of short duration, or in the hospital are usually appropriate and don't pose a significant risk.  Long-term use is a different story altogether. 

Narcotics are strong pain killers.  Some of the common names are Norco, Vicodin, Percoset, Oxycodone, Hydrocodone, Dilaudid, MS Contin, or Morphine.  They are in the highest potency class and have a definite risk for abuse.  How high the percent of addiction goes isn't very well known and therein lies part of the problem. I've kind of divided them into three categories for myself as follows:


The Good:  I have a lot of people on narcotics whose life is better by them.  Usually these are older individuals who have some old age bone pain and some trouble getting around because of a bad hip, or knee, or back.  They usually use less than the prescribed amount and take the medications conscientiously and with purpose.  They tend to have the fewest problems and get the most benefit from them.  They also understand that the narcotics won't eliminate the pain

The Bad: Often these are people who have something legitimately wrong with them (some sort of accident at work, or car wreck, or something) and get started on Narcotics.  Unfortunately narcotics don't get rid of all the pain.  Usually it takes the edge off some of the intense pain, but doesn't get rid of chronic pain that well.  This group usually wants more of their pain covered by the narcotics, so they come in and ask for more, hoping that it will help their pain.  This just gets them an escalation of the narcotics, without much more pain relief, but more side effects and a greater physical and psychological addiction to the "medicine".

The Ugly: This group is usually pretty easy to spot over time because they come in with increasing needs and are wanting early refills of their meds.  They get a very high dose of medications and it keeps escalating.  They have "seeking" behavior where they keep pressuring the doctor for more.  This group is looking for a high and/or selling the medications for money.  They are trouble from start to finish and can mire your practice down very quickly with how often they come in and want to be seen for a million different things.  This group and the previous group also tend to rush the clinic on Friday afternoons trying to get their prescriptions filled before the office closes for the weekend.  

The worst thing about narcotics is the addiction that people have on them, both physical, but more so emotionally.  The thought of going without their medications is terrifying for them.  They have become dependent on the medications for so long that they don't know how they'll get on without them.  The sad/interesting part is something I learned from a pain specialist in medical school  He would ask them to tell their "pain story".  They would start with how it all started and the pain would be an 8 or 9 out of 10.  Then they tried this medication, or that intervention, or this injection, or that physical therapy and always when he would ask them throughout their story they would rate their pain with the different treatments is was always an 8 or 9 out of 10.  But when he would say that he was going to stop the medications because they obviously hadn't worked they would become very agitated with that plan.  The fear and anxiety would be very high. 

It's kind of a weird dynamic telling a patient who is in pain that I know these narcotics will help your pain right now, but it comes with a very high price including physical and psychological addiction and the pain relief will only be partial. 

It's a very complicated picture and if there was an easy answer to how to handle this we would have the problems that we do.  But here we are.  My approach (with everything, not just pain) is to maximize what we can with diet, weight loss, exercise/strengthening and mind exercises.  Whatever is left over we deal with medications.  I try to let them know that this will never get rid of their pain completely, but will hopefully let them do some of the things they want to.