During his talk, Dr Mariano sought to address a common situation encountered by pain physicians in their every day practice: should they reinstate opioid treatment in patients successfully taken off these medications?
The answer is: it depends on the patient,
- on whether they have a history of substance misuse,
- on their functioning, and
- whether they are actively involved in their own pain rehabilitation.
“This is the primary directive of opiate prescribing.
Yes, the primary directive of opioid prescribing is that it depends on the patient. That’s exactly why standard dose restrictions for opioids are not medically sound.
No matter what the answers to those other questions, safety always trumps pain relief,” said Dr Mariano. “So that the answer is, if you can’t use opioids safely, if you can’t guarantee appropriate risk mitigation, you shouldn’t do it.”
According to Dr Mariano, ”What ends up happening to the average provider in the real world, trying to help people, [is that they] find themselves alone in the room with a patient who is overwhelmed and overwhelming the provider, and the only choice left for the provider seems to be to give up, give in, and get these medications.
Being caught between what they think they should do, and what they find they really can do.”
To get out of such situations, what should healthcare providers (HCPs) say? Providers need to be aware of their own reactions during this difficult process.
The doctor’s point of view is common in this publication and shows how “the other side” is thinking.
Dr Mariano identified 6 common situations and sought to provide advice for each scenario.
1. Negotiations and false hope.
- It is important to tell patients that learning self-management strategies is a difficult process. The goal for HCPs is to develop a plan that is safe, make sense medically, and is sustainable.
- Patients would say: “Of course I want to get off these medicines, I just need a few more for a little while longer.” But increasing doses to take people down later is nonsensical, it only worsens the issue, says Dr Mariano
- A patient would say: “It is your job to help me. Why won’t you give me what I need to find some relief?” or: “I shouldn’t have to suffer like this, nothing else works. What am I supposed to do?”
2. Appeals and ethical confusion.
In some instances, the patient will even “absolve” their HCP, saying: “I don’t care about the risks, why should you? I need these pills to survive.” The simple fact is this, says Dr Mariano, “these are your responsibilities, not your patients’. Your duty may be to wean this person, as your duty is not to harm.”
Avoid taking complete responsibility for urgent and complete pain relief in a patient who is not going to engage in what we know is far more important: being actively engaged in dealing with other life problems. “The bottom line is, there are patients we can’t help,” he added.
The patient comes and says: “How can you take away the only thing that helps me, you’re ruining my life!” or: “I was doing just fine, now I can’t do anything.”
This brings up the “guilt scale.”
I’m disgusted that the problem of involuntary pain relief reduction is viewed as a problem the patient is causing for the doctor.
How can any doctor understand chronic pain when they are steeped in this kind of thinking?
Here, HCPs need to be careful in assuming that patients are stable. Providers need to help their patients identify problems other than pain, and try to get them the help they need.
The most common reason patients go to their doctor is because they need pain relief. If the doctor cannot or will not do that, it is NOT the patient’s problem.
3. Blame and guilt.
Sometimes, patients accuse their HCP of being responsible for all their problems: “You’re the reason I’m drinking! The only reason I’m drinking is because you won’t give me enough Percocet.” It is very easy and natural to respond defensively in such situations, however, it’s not helpful.
4. Accusations and anger.
If a person has problem with substance abuse, taking them off opioids is not synonym to refusing to help this person.
Another group of patients may be misusing, while having poor expectations as to the kind of relief they can get through medications. These patients are not looking for drugs—they are looking for relief.
That is exactly the point. If a doctor cannot relieve a patient’s pain in any other way, then opioids are appropriate. Opioids can also be necessary while the patient continues searching for a cause of their pain, which doctors rarely do outside of their specialty.
And they may say: “I’ll take what I need, and I need to use more medicines, because you are not giving me enough.”
In these situations, it is helpful to explain to people that medications do not work equally well for everybody, to provide them with realistic expectations, and to frame the issue by pointing to the fact that some people are opiate non-responders
This states that medication don’t work equally well for all people, yet this publication is constantly reporting on another guideline using standard doses of opioids.
5. Threats and fear.
Some patients start threatening their provider: “I’m going to go over your head, I’m going to call your boss, the Senator, I’m going to file a complaint with the State Medical board…”
Although it is easy to feel intimidated in that situation…
A doctor’s job is to deal with patients and it is NOT the patient’s job to tip-toe around the doctor’s feeling. Doesn’t it occur to them that a patient might be terrified and furious when a doctor threatens to cut off their pain relief?
Dr Mariano recommends HCPs acknowledge the fact that there is coercion, and seek advice from pain specialists, “because you know you’re not going to get in trouble if you document your rationale and show that you are seeking advice from your colleagues.”
When patients threaten of suicide, always consult a mental health professional..
Threaten? Wanting to kill yourself is now considered a threat against the doctor? What about the threat against the patients themselves?
6. Challenge and doubt.
The average practitioner has very little training in pain, and even less about the specifics of prescribing.
Here, the key is not to hesitate, and seek consultation, as it is important to believe that you are doing the right thing when a patient believes you are doing the wrong thing.
This is terribly common today: doctors doing the wrong thing, yet believing they’re doing the right thing.
This is a problem with the doctor, NOT the patient.
Dr Mariano recommends telling patients to consult the Veterans Affairs or Centers for Disease Control websites, so as to get them to realize they’re not making this up.
But now we know how politically and financially influenced these government agencies are. They are merely spouting the same propaganda as the “addiction specialists”.
So, when tapering, “be very clear about the rationale—safety is your major concern—be very specific about the process, let the patients know about what is going to happen, and then follow through on it.
And then, be empathic but not apologetic, because bad care is not an option,” concluded Dr Mariano.
What does he mean with “bad care is not an option”? For whom and for what? Bad care happens all the time and for pain, it’s downright awful.