One old guy yelled 31! – and the place broke out in laughter. After a moment or two, another guy yelled 52! – and more laughter erupted. Then a depressed-looking guy in the corner yelled 29! — followed by silence. He yelled again, 68!—and again, the room was silent.
The new recruit asked the guy in the next bunk what was going on. The guy answered, “we’ve been together so long that we know each others’ jokes too well—we decided to just number ‘em and save us the time.”
The new guy asked again, “but what about that guy in the corner?”
“Oh—that’s just Slim—he never could tell a joke.”
I recently exchanged emails with a patient about his complaints of back pain. After reading about his symptoms and history by email, I told him– prior to his first visit– that I would consider treating his back pain and his use of opioids using buprenorphine, but I would not prescribe opioid agonists.
We met and started buprenorphine, but after the second or third visit, he began asking for opioid agonists.
A couple specifics about the case: the patient is under 40, and has been treated for years using high dose opioid agonists—without a formal diagnosis for his back pain, which is localized and aggravated by activity. The symptoms at least appear to be far less disabling than the symptoms some of my other patients; he gets around without any assistive devices such as walker, cane, or wheelchair, and he complains that the pain interferes with his basketball-playing.
We exchanged a couple messages, and I made the mistake of describing the appropriate increase in enforcement by the DEA—which led the patient to assume I’m afraid to treat him. He also suggested that I judged him because of his tattoos and piercings. Finally, he thought I was being dismissive by not ordering an MRI of his spine.
So often when I try to explain that opioid agonists are not appropriate, I end up repeating myself—even to the same person. So I am sharing this exchange, hoping that I can refer others to my comments, and save all of us some time. Like in the old joke—I’ll just say ‘April 3, 2012!’
My response to the patient:
As I read your note, I realized that the discussion we are having simply comes down to whether a person TRUSTS his/her doctor. I’m frustrated that I cannot get you to trust me, and I hope that you are not injured, at some point, by a charlatan who does win your trust.
I hear your frustrations, and have answers for some of them. I also have frustrations; mine being that so often, people come to me with their minds attached to an agenda. In those cases I am powerless to educate, as everything I say then becomes a challenge to overcome—rather than a medical opinion, formed from knowledge and experience, for the person to consider.
In reply to your specific comments:
I mentioned the DEA actions in order to explain that portion of the opioid issue. You seem to have the opinion that I am holding back treatment out of fear of the DEA. That is NOT the case. If there were NO agency that regulated prescribing in any way, my decision would be the same. My recommendation for you, in regard to the use of opioids, is MEDICAL, not political or legal.
I explained the medico- legal atmosphere surrounding chronic opioids so that you understand the current standard of care—so that when you find that it is only the shady docs who give you the opioids that you want, you know why—and so you know why their office is open one week, and padlocked the next.
I can assure you that your tattoos and body piercings never played a role in my decisions. I suppose that some psychiatrists would argue that EVERY part of a person should be considered as one more piece of the puzzle—i.e. maybe a person with major body art is more impulsive, etc… But honestly, I never gave yours any consideration, pro or con.
I order MRIs in some situations. But I know, from your symptoms, what your MRI will show—and more importantly, what the results will mean. You do not have radicular symptoms. You do have muscle symptoms. Your MRI will almost surely show degenerative joint disease at multiple levels—which would be a common finding in someone your age who has no pain. Every person who has had an MRI obtains a list of horrible-sounding things—but those horrible things are NORMAL. MRI’s should not be used as a ‘shotgun’ approach to diagnosis; they should be used to verify findings suspected because of the history and physical. EVERYONE has some type of pathology on MRI—and it is shameful that some doctors use those findings to justify a litany of costly procedures that have no chance of benefit to the patient.
In other words, I didn’t order an MRI because the results—no matter what they were– would not alter the course of treatment. In medical school, we used to live by that rule; don’t order a test unless it has at least some chance of changing the diagnosis or treatment. These days, tests seem to get ordered for far less reason!
Whether to treat chronic, nonmalignant pain with opioids is a complicated question, which is why I spend so much time on the topic in my blog. There ARE people with severe injuries, and even in THOSE cases, the value of opioid agonists is debatable. In medicine, doctors must be guided by evidence—otherwise we end up guided by guesses, clouded by ego and emotion. The evidence shows that opioid agonists destroy function, even as the person taking them insists that more are needed. But as you will read in my blog, I cannot accept the extreme position that they are NEVER indicated. In cases of severe injury, it is difficult for me—and I suspect many doctors– to write opioids off completely.
In the case of a person who can, as in your case, play basketball (!), the thought of prescribing opioids is, frankly, ridiculous. If you came to my office wearing a suit—heck, wearing a tuxedo—and told me you were a senator from the political party I prefer, and that pain bothers you every time you wave from the end of a train– and then you gave the same history as your own– I would say that opioid agonists are not indicated. Not even close.
From all that I know, your problem is not surgical or even anatomical, and you will only get worse if you treat your pain using opioid pain medications. Your best chance for good health will come from exercises that improve flexibility and aerobic tolerance—i.e. stretching and exercise, gently at first, and working up as tolerated. That’s the right path, in my opinion.
For readers—I hope there is something interesting in the exchange. Comments are welcome, but as I’ve written before, I don’t publish mean-spirited messages from the people who think I’m too stingy with pain pills. If you want to make a point, I’m thrilled to share it—but personal attacks will go straight to the trash bin. It speaks to the emotion surrounding the pain pill issue, I suppose, that I even need to make this request. I’m truly sorry that you are hurting.
Soldiers photo available from Shutterstock.