Saturday, September 15, 2007

Video on Opiate Medication and Pseudoaddiction

This video on chronic pain, pseudoaddiction and the appropriate prescribing of opiate medications was produced by the Maryland Board of Physicians. It touches on a lot of subjects, but is primarily aimed at doctors and focuses on improving the ability of doctors to prescribe opiates safely, effectively and in accordance with the law and also on helping to allay the fears doctors have of losing their licenses or addicting their patients if they use these drugs to treat pain. The link is at:

The video begins with two actors playing a doctor and a patient and depicts an interaction between a skeptical doctor and a nervous and defensive patient who has just moved into town and is looking to get a refill on the script for morphine she got from her previous doctor. This part of the video has a lot to teach both doctors and patients, as it shows doctors a classic case of pseudoaddictive behavior, and also shows patients how not to behave when they go to their doctor's office, particularly if they are a new patient.

The actress in the video walks into the doctor's office and gets right to the point: I'm here for a refill of my pain medication. The doctor gets a little defensive and starts to question her about the necessity of such a high dosage, and she in turn gets angry, defensive and frustrated as she tries to reason with the doctor and convince him that she needs this medication to function, nothing else works and not only are NSAIDs useless, but they gave her a GI bleed. The doctor remains skeptical but finally offers to call and discuss the matter with her previous doctor.

The doctor in the video is oblivious to the impact his attitude is having on the patient, and no doubt thinks she may be an addict based on her excitability and frantic demands for medication. But the patient has good reasons for being as nervous as she is, as she is utterly dependent on this medication to function, and if she is cut off abruptly, not only will she have to deal with the torture of her pain, but could go into seizures or withdrawal. She is, basically, looking at the barrel of a gun and wondering if the person holding it is going to shoot. This would make anyone a little nervous.

A chronic pain patient faces feelings like this every time he or she walks into your office. Going to a doctor's office, especially a new doctor, can be like facing your own execution: you are in a constant state of anxiety wondering if this will be the time that the medications you need to function are going to be taken away from you based on a false accusation of abuse or diversion, or simply because the doctor is no longer "comfortable" in prescribing them for you. This is particularly true if you already have a shaky relationship with a doctor, or you're a new patient and don't know what to expect.

Doctors need to understand just how incredibly stressful this really is and though the doctor in that video is asking his questions in a calm, straightforward way, many doctors will confront their patients in a far angrier and more accusatory tone simply because they asked for an increase in their meds as tolerance began to set in. That pseudoaddictive behaviors such as anger and defensiveness and frantic requests for meds can arise under these circumstances is something doctors should be prepared for.

At the same time, patients need to be aware that walking into a new doctor's office and immediately requesting a refill for a narcotic is practically guaranteed to get you labeled a drug-seeker. If you still have any credibility left after that one act, it will quickly be squandered by getting angry and defensive as the patient in this video does. One of the cardinal rules of dealing with doctors is never, ever lose your cool and get angry or defensive unless the doctor is doing something outrageous. While many doctors seem to feel they can vent their anger at you at will, few seem willing to reciprocate by allowing you to act human from time to time. Getting angry can and often does result in you getting denied treatment, and could get you blacklisted as a "problem patient" or drug-seeker as well. No matter how much you're provoked, try to respond calmly and with reason and logic. This doesn't mean be a doormat and let the doctor abuse you: you should definitely resist that. It just means don't give him a reason to be angry with you, and try to be as respectful as possible, just as you would in a less stressful situation with anybody else. Remember the doctor has a right to question you about your medication as well as ask you what other treatments you've tried. Try not to get defensive about this.

The second thing you should never do is walk into a new doctor situation without a complete copy of your previous medical records, and if you have a really good relationship with your previous doctor, you should ask your old doctor to contact your new doctor in advance to discuss the reason for your visit. It is far better for a doctor to hear you are looking to transfer management of your pain condition using opiate medications from your physician than to hear it from you. This will also give you advance warning if the new doctor is unwilling to treat your pain, so you won't have to wait weeks just to get rejected. If this isn't possible, you might want to suggest that the new doctor call your old doctor right from the word go rather than waiting for him to suggest it. Your best advocate in cases like this is the doctor you already have, as doctors are more inclined to trust another physician than you, and your new doctor can more easily justify prescribing meds if he understands the reasons your previous doctor did so.

While that video might be a little cheesy (where did they get that music from?), what it lacks in style it makes up for in substance, and is definitely worth a thorough review by both doctors and patients.

No comments: