After decades of liberal prescribing of opioids and different levels of care – as Shakespeare would have said – “the die was cast.” Trying to forcefully undo the die is simply not the way the recent opioid scare will work, writes Dr. Firdos Sheikh.

It is rather disruptive to say the least. It’s neither going away nor is it going to fade without us first stopping the wheels that put this in motion. The causes have to be identified before we can stop the wheels. Sticking a scare in the spokes of this wheel, already in motion, will only catapult the entire vehicle.

Doctors are being harassed the most in this opioid web. Be it the emergency room, the primary care doctor or lastly the specialist. The instant gratification medication completely tips the boat for a developing a meaningful pain management protocol in days to come. And snatches away the most needed element called endurance that is the core of pain management.

Let’s start at the very beginning.

Providing a Temporary Quick Fix

Be it the case of a motor vehicle accident, domestic violence, assault, law enforcement violence or work-related injuries, neglecting or delaying timely help is the culprit. In the ER there is pressure to justify hospitalization, hence they are in a rush to give a quick fix and discharge the patient. Narcotics facilitate that step, and the ‘die’ is cast. That’s the first step that needs to be fixed.

Once a patient tastes a narcotic, they will seek that same instant gratification moving forward.

Secondly, primary care are under pressure not to refer out patients to a specialist, so they start trying to handle pain without defining the actual underlying pathology nor understanding the ramifications of such “band aid” treatments.

As a result, the patient keeps spiraling under the pretext of “not feeling pain” from acute pain, that then transforms into chronic pain, and that transforms to chronic fatigue syndrome and ultimately the dreaded fibromyalgia taboo sets in . And if luck would have it, they might finally trickle down to see a specialist. Several months, a little too late!

Narcotics on board, muscle-less, with worsening pain and now completely dependent on their pain medications.

In the journey thus far, most primary care doctors seldom reach the actual initial pathology as they are not specialists. They go down the dreaded path –start to increase pain medications, try to order therapy, patients often hit and miss therapy due to psycho-social reasons and therefore continuity of healing and outcome is always suboptimal. Narcotics cover the symptoms. Patients instead of healing push harder under the pretext of being pain free, when in fact the pathology advances and the pain is increasing. When the demand for stronger pain medications becomes an issue, Primary Care try to order an MRI. It gets denied and then by default as they cannot handle this now progressed pain, they send the patient to a specialist.

The specialist picks up at a complete disadvantage as now patients are a twisted and tangled bundle of nerves in extreme pain.

As a neurologist, I need to first see how many layers were covered up and with how many different medications. Then peel down the complex pain syndrome, like the layers of an onion, and wade my way into the root cause of their pain. Worse still is revelation of the extension and expansion, as well as worsening of the symptoms over the years.  And the extent of damage that comes from untimely intervention by a specialist.

Ironically, many times it does get to the “nerves” of the patients, who have now become irritable, angry, demanding, and unreasonable, as they seek larger doses of quick fixes not understanding that those very narcotics are the culprits that allowed, under the garb of a pain free state, not just in worsening the symptoms but also facilitated in spreading the pain as it progressed to different parts of the body. This eventually at times culminates into the dreaded fibromyalgia state.

I have seen this way too many times. I take a deep sigh and start educating.

“Narcotics and pain medications are only ‘band-aids,’” I tell my patients. “They don’t cure. they just cover up the symptoms.”

And what is bad is that under this shield of no pain one can keep pushing beyond the threshold simply because the pain pills camouflage the perception of pain and one does not know when to stop as it blurs the lines of reaching the limit.

Before Damage Sets In

So, in a sense the pain gets worse as the wear and tear gets worse. By now the pain pills are not enough. Patients ask for more pain medications, they start being perceived as ‘drug seekers,’ addicts instead of recognizing that the disease has advanced.

They get treated like they cannot be trusted, but what is actually happening is that the underlying as yet undiagnosed/untreated condition has only gotten worse. Patients feel humiliated as they are questioned about the medications by the doctors and pharmacists. They lose their confidence & they get depressed. Depression tends to heighten the perception of pain, and we push them further down into the pit of pain.

Once I have the attention of the patient, I have to start convincing them to decrease their narcotics and to try other medications that are not harmful.

They are reluctant. They simply have no ability to endure and wait for medications to start working. Steering the wheels away from narcotics is like swimming against a very powerful current.

It takes time, education, other less harmful medications that take time to start helping and other interventional pain modifying modalities like therapy, trigger point injections, nerve blocks and sometimes epidural need to be tried. Building endurance is an uphill battle. It’s a balancing act.

As we write for medications that we think would help us wean them of their narcotics, Insurance providers fight us by denying and putting us through a prior authorization saga that I talked about in part one of my series. (Siliconeer, December 2018)

Diagnostics are denied, whether it’s a nerve condition study or an MRI of the spine, we have to convince and push a lot of paper to obtain the authorizations. Meanwhile delaying diagnosis makes pain management even more challenging as we fight between obtaining authorizations for effective drugs and educating patients about the dangers of chronic narcotic usage.

Like this is not enough, we are pressured by the DEA and the pharmacists. Pharmacists have to get the following information from the doctor I am told: (There is no letter informing us of this added duty. The pharmacists do not send us any communication of this added volunteer service that they expect from doctors).

  1. Do you have a pain contract with the patient?
  2. Have you done a urine test / swab to check if they are taking medications?
  3. Have you checked the CUREs website to see if anyone else is prescribing the medications?
  4. What medications have you tried? Please list all the medications.
  5. How long have you seen this patient? What is your plan for this patient?
  6. How long do you plan to give them the narcotics?
  7. What is the ICD 10 code?
  8. Worse still, they ask us what is the diagnosis for this ICD 10 code? Why ask if you have no clue about what you are asking?

All valid questions but who are the doctors answerable to?

  1. How is this information going to help a pharmacist make a decision to dispense the medication?
  2. Where is the time for a doctor to answer all these questions?
  3. When the technician calls you and asks all these questions, or faxes a questionnaire, when is the doctor going to find time to do any of this for every single patient?
  4. While this protocol is being implemented, as I am told, the DEA expects this from the pharmacist, how is a doctor going to pacify a frantic angry patient who calls the office as they are at the pharmacy and are tired of waiting. And who then will help the doctor to help satisfy a patient in the clinic who is now getting delayed? Who will be again answering to the grievances filed by the patient against the doctor? Why are we taking on this liability and burden forced upon a doctor for absolutely no reason? Wonder sometimes, what is the actual role and definition of a doctor.
  5. How is a doctor going to handle seeing patients in the clinic and taking care of patients who have left the clinic?
  6. Are doctors baby sitters of the pharmacists, or are the pharmacist’s regulators of doctors?
  7. How is this service, added stress and burden going to be compensated?
  8. We have to provide the pharmacies and laboratories the ICD 10 codes so that they can bill?
  9. That increases our load, and for what? I again ask, “Can’t I just be a doctor?”  Can’t I just “heal?” and not have to deal with so many people at so many levels.

I write the ICD 10 code on the prescription, and the pharmacist calls my office asking what the ICD 10 code stands for! Just google it!

Interns, technicians at pharmacies and laboratories dial a doctor’s office with questions that help facilitate their learning it seems. If a doctor expresses their frustration about frequent interruptions and then their inability to comprehend what is being said, doctors are threatened by asking if they should not dispense the medication. Or have the patient wait longer until all their questions are answered.

So now the doctor and patient are held at ransom!

I have tried to find how any of those questions that we are forced to answer help a pharmacist make a decision on

  • Whether they want to dispense the medications or not?
  • How are they qualified to make any clinical decision?

I called the DEA and expressed my frustration. They stated that they fully understand my frustration but that I had to complain to the college of pharmacy.

As a doctor, again I realized that there are no clearly defined avenues for clarifying our concerns. Like everything else we are dumped upon, truckloads of regulations and requirements by multiple departments, all using a doctor to justify their charges and protect their liability.

Doctors are suddenly answerable to:

  1. A pharmacist
  2. A laboratory
  3. A radiology department
  4. A pathology department

All have similar procedures. All beating their chest, asking us to justify, to discuss plans, and satisfy criteria imposed by many other departments.

All day the doctor encounters different entry level assistants asking doctors questions that have complex answers that they cannot comprehend and don’t have a clue. And the doctor struggles to get past these hurdles to be able to reach a patient so that they can just finally be a doctor.

But in spite of all these challenges, intrusions, demands, questions and documentations, the expectations from a doctor is that they don’t complain, and simply play God, and be perfect in everything they do, because the measuring yardstick has many spokes in its wheel that can stab the character, selfless work, tireless efforts and sleep deprived hard work of a doctor at many, many levels.

Why? Because, apparently a doctor puts themselves through all of this just to make money?

Go figure. More on the narcotic saga in my next article.