I was taken aback when a “new-to-me” patient demanded that I refill his pain medications.

The middle-aged man was in a wheelchair and had an extensive history of trauma. My co-worker in the outpatient clinic was his regular PCP, but the patient was unable to make an appointment with him and showed up in my office asking for prescription refills.

The number of controlled substances he needed to have refilled was beyond overwhelming to me. I do not have a background in pain management, and I did not know this patient, so I felt very uncomfortable with the number of controlled prescriptions I needed to fill.

I explained that it would be best to see his PCP to get his medications since I did not know his history. He became very defensive, told me he was in excruciating pain, explained his old injuries, and said he was entirely out of his medications.

 

Physically dependent

I gave him enough prescription refills to last until his next appointment with his PCP, which I scheduled before he left. I explained why it was essential to book appointments regularly with his regular doctor so he could receive the most appropriate care.

He said he understood and thanked me but still appeared a bit agitated. I believed his pain was real but felt that he was physically dependent on his medications and was at risk of withdrawal if I did not refill them. I also believed that he should consult with a pain management specialist.

 

The challenges of managing pain

Ethically managing chronic pain is one of the most significant challenges for a physician.

We want to help our patients, but we don’t want to overprescribe and risk them having physical dependence or addiction—or jeopardize our medical license.

I find the most challenging cases along these lines involve “new-to-you” patients who have chronic pain and come for medication refills. Do we automatically give them a refill? Do we assume they are drug-seeking? Do we form false assumptions about them?

I have met my fair share of drug-seeking patients, and it’s challenging to work with them in an ethical and empathetic manner. Although there are red flags associated with this behavior, I always struggle with the question, “What if I am wrong and this patient is experiencing legitimate pain?”

 

 

Alternatives to medications

We don’t always have to prescribe drugs for pain. Other treatments can sometimes be used as substitutions for (or in combination with) medications, including:

• Acupuncture

• Massage therapy

• Physical therapy

• Spinal manipulative therapy

• Biofeedback

 

 

Use your best clinical judgment

Physicians have extensive knowledge and clinical training in medicine and patient care. It’s essential to utilize this when dealing with a problematic chronic pain management case.

Although it is important to be aware of the warning signs associated with drug-seeking behavior, such as dependency, withdrawal, and addiction, treating your patient’s pain is important so they can have a decent quality of life.

Keep in mind the stepwise approach to pain management, which starts with non-steroidal anti-inflammatory drugs (NSAIDs), transitioning to low-dose opioids, and then finally to high-dose opioids if necessary.

An article published by StatPearls on the WHO analgesic ladder suggested the following:

Anekar AA, Cascella M. WHO analgesic ladder. In: StatPearls. StatPearls Publishing; 2022.

 

• Prescribe appropriate medications.

• Balance dosage with a drug’s side effects.

• Consider rotating opioids to reduce side effects and improve analgesia.

• Educate patients on the drugs’ uses and potential side effects to maximize benefits and avoid misuse.

 

Explain your thought process

Chronic pain management is not a ‘one-size-fits-all approach.’ It often needs to be modified depending on the patient.

Here are some ways to communicate the thought process behind your pain management strategy to patients and family members:

• Explain why opioids may or may not be the best option for this patient at this moment.

• Discuss the risks of long-term NSAID use.

• Suggest alternative therapies in combination with pain medications.

• Explain the risks of overdose, dependency, and addiction to certain controlled substances.

• If you feel you cannot manage their pain, explain why a pain management specialist would be a good fit for them.

After you formulate a pain management plan with the patient, it’s essential to have them sign a pain management contract when you’re prescribing controlled medications.

Sample patient agreement forms. NIH.

 

This contract often includes rules and guidelines a patient must follow. If these are broken, you have the right to stop prescribing them controlled substances. Pain contracts not only hold patients accountable but can also protect you legally.

 

Consult with specialists

Knowing your limitations is one of the most important aspects of being a physician.

I am a primary care doctor, not a pain management specialist. Although I feel comfortable prescribing some pain medications, I have encountered instances where managing pain was way out of my wheelhouse.

Consult with a pain management specialist if you feel you do not have adequate training or experience to treat your patient’s pain appropriately.

You could speak with specialists in orthopedics for a potential steroid spinal injection for chronic pain, palliative care for cancer-related pain, or a pain management specialist for high-dose opioids or buprenorphine/naloxone (Suboxone), which is used to treat opioid use disorder.

Suboxone. Drugs.com. Updated August 1, 2022.

 

These specialists can be a saving grace for your patient and may provide an opportunity to learn about other pain management strategies. Communicate your reasoning for consulting with specialists to your patient, so they understand the course of action.

 

Consider other medications

The StatPearls WHO analgesic ladder article suggested the following non-opioid pain medication alternatives:

• Nerve blocks

• Steroid injections

• Suboxone

• Muscle relaxants

• NSAIDs

• Antidepressants

• Gabapentin

  Gabapentin. Drugs.com. Updated May 23, 2022.

   

 

Tap into your knowledge

I think that so many patients come into our office or ERs demanding pain medications that we tend to become defensive and, as a result, question their pain levels.

Instead of reacting this way, use your knowledge and training to gather a complete history, perform an extensive physical exam, assess their medication history, and prescribe the appropriate pain management.

Whether NSAIDs are combined with low-dose opioids, steroids, a referral to a pain management specialist, or high-strength opioids, you must use your best knowledge to formulate a pain management plan.

When you sit at the bedside with the patient, communicate your strategy with them and their family, showing empathy for what they are going through.

Use your best clinical judgment with honesty and compassion.