Balancing opioid medication in chronic pain

KevinMD.com

She walked in with a cane, bent over like a question mark. She was in her seventies and as sweet as people in that age group tend to be. I think most of the cranky ones don’t make it that far. She was something of an emergency because her doctor had just passed away, and it was time to refill her medications. It would not be safe for her to wait the usual two to three weeks that it took for us to accept a patient who was on chronic controlled medication therapy at my clinic. My staff had just saved her faxed chart into her digital medical record, and I was starting with page one of what was, of course, a lengthy tome.

“What medical problems bother you the most?” I asked as I started reviewing records that were decades old and started moving forward. I always start at the last page, so I have an accurate chronology in my mind when I decide on treatment.

“How long have you had joint pain?” I asked.

“And your back?” I queried.

“Not quite as long … I have five collapsed vertebrae,” she said.

“Accidents or falls?” I asked.

Those were also documented as compression fractures. Injected kyphoplasty but no surgeries. Probably unsafe to put under general anesthesia. Cardiac, liver, and renal function were OK for mid-seventies, but hey, who wants to explain a bad outcome on the operating table?

“What medications are you taking for everything right now?” I asked.

“Well, I’m on 30 mg of morphine …” “Oh,” I thought.

“Three at a time,” she continued. “Crap,” I thought.

“Four times a day.” She finished. “Holy Hades” went through my mind in a less censored format.

As I was doing the math and coming up with 360 MDE and starting to sweat, she kept going.

“And,” she said proudly, “thirty milligrams of oxycodone.”

I quit writing and sat back in my chair, wide-eyed.

“Three at a time … four times a day,” she finished.

“OK,” I said as I started running through my mind who the best dementia specialist in the area was, while typing her name into the prescription monitoring program. Sweet little thing has lost a few marbles, I thought. Understandable at her age. But there it was. Exactly as she said, for eight years. 900 MDE. An even ten times the CDC caution limit of 90 MDE per day for chronic pain treatment.

I sat back and thought about what to do. Should I send her to a pain specialist? Why? Almost all of them in my area are interventionists. What procedure are they going to do for this poor lady? And she’s stable on her current treatment. Do I continue her treatment? I’m from a state where the politicians and law enforcement discovered that they could practice medicine without bothering with medical school. Just take the CDC’s 2016 suggestions, meant to help doctors make decisions, and pretend that they are suddenly the “national practice of medicine” and lock up anyone who doesn’t “follow” them. And by following, I mean interpreting them in the same way as whatever politician, prosecutor, or law enforcement officer happens to be in your area. Which is variable, but hey, ignorance of the law is no excuse. And neither is an ignorant law, for that matter. But back to the issues at hand.

She had already been on these medications for a very long time. I am not “starting” her on opioid therapy, so she does not fit into the CDC’s 50 MDE guidance suggestion. She is on more than 90 MDE but qualifies for “palliative” pain treatment. Meaning we can’t fix what is wrong with her, and she’ll have to tolerate the pain she is having. Everyone wants to promote non-narcotic treatment of pain these days. And that’s fine if your patient hasn’t been on opiates long term. Once they are, their pain tolerance drops due to hypersensitivity, and it is almost impossible to reduce them without tremendous suffering and a high risk of comorbidities like stress-related heart attack and stroke. Or just suicide. The number of people who have killed themselves in pain since 2016 is usually ignored. My state had a documentation requirement when you go over 50 MDE, but she clearly met those criteria. Objective imaging like MRIs, CT scans, and X-rays. Blood work. Drug screens, etc.

In the end, I told her that I was going to reduce her medications carefully and see if the adjustment was tolerable for her. I dropped her down to just two oxycodone pills at a time, four times a day, going from 540 to just 360 MDE, making a total of 720 instead of 900, a drop of 20 percent. That’s a lot, but I told her she could come back if it was intolerable. I also half-jokingly told her that if she happened to pass away from any cause, the authorities would probably lock me up for writing that lower-dose prescription. Somehow, they have it in their heads that if someone comes to you on what they deem to be “too much” opiate medication, or combinations of medications that they don’t like, or were started for reasons they don’t agree with, that the correct policy is to just not prescribe. That’s how you kill people. And doctors try to avoid that. Except Kevorkian. Being his resident must have been the easiest training in the world. You only get in trouble if the patient IS still alive during morning rounds.

She had some GI upset and felt a tremendous increase in her pain but toughed it out. The increase in pain assured me that she had not developed hyperalgesia, and that titrating up had not been based on a titrate-to-effect policy that had not considered opioid-induced hyperalgesia. Or if it had, her previous PCP got lucky. I sent her to a pain specialist, and they said what I expected, “There’s nothing for me to do.” Over the next year, we were able to slowly get her down to just 360 MDE. She was no longer able to carry out her activities of daily living and had to go to an assisted living facility. She was not happy about this but was always cordial. An angel under the circumstances.

She could not, however, understand why I had to reduce her dosage at all when she had been doing so well for so long. I know I was cognizant of the threat of criticism or even prosecution for continuing her care. How much did that influence my decision? Would I have been a hero to continue her on the previous dosage if it had maintained her independence a few more years? Or a villain in the news if she had died in her sleep from any cause at all? I don’t know. And neither does anyone else. In the end, even when we practice in accordance with our education, training, and experience. Even when we do everything right to the best of our ability. The biggest things are still out of our hands.