The Other Opiod Crisis

I was prompted to write this piece because of a recent surgical procedure and lengthy hospital stay, in late 2018.

At that time, I underwent an extended back surgery involving a four level fusion of the lumbar area. I previously had undergone four procedures and recovered quickly. My surgeon stated that he “redid my spine and virtually straightened it.” He informed me that my pain would be considerable and that I would probably not be able to sit for an indefinite period of time.

After surgery, I was on hydrocodone around-the-clock. After a four-day hospital stay, I was transferred to a rehabilitation facility. Pain medications continued, and I could not even sit in a wheelchair. 

When it came time for discharge, my attending physician at the rehabilitation facility discussed sending me home on hydrocodone, not every four hours, but every eight hours. As a physician, my discussion centered around the fact that I was still in need of pain medication at four-hour intervals and felt that this taper was rather rapid. He informed me that he was no longer going to be my prescribing physician and was not comfortable prescribing medication every four hours. He suggested that I contact my surgeon. 

My surgeon, when notified, informed me that this is not an infrequent occurrence on his patients being discharged from rehabilitation. He without hesitation prescribed the same dose with the understanding that I had easily tapered from narcotics from previous surgeries. My goal was to get off of pain medication as soon as I could. 

When my attending surgeon refilled my prescription, I called my local CVS pharmacy, (where the prescription had been sent), and was told that they would not refill the prescription “because I had received two prescriptions from two other providers.” The obvious intimation was that I was “doctor shopping.” When explaining to the pharmacist that I had two prescriptions from providers at two different hospitals, I was informed that, “I’m not risking my license for you.” 

I do not think this is an unusual circumstance, and patients at this time with legitimate need for narcotic prescriptions are being dismissed or short-changed. 

I have worked in the field of addiction for over 30 years. I have had a private practice in addiction medicine for 15 years with an emphasis on treating patients who are opiate dependent, and chronic pain patients, who are opioid dependent secondary to their chronic pain. We have offered a comprehensive multidisciplinary treatment program, including medication assisted treatment, individual counseling, family counseling, endorsing the 12-Step participation, and doing urine and medication monitoring. 

I am have become aware through several of my patients’ reports that their providers are extremely reluctant and in many instances refuse to refill opioid prescriptions. These are patients that have been on medication for long periods of time without increasing their dose or filling their prescriptions early. Many large group practices are telling patients that they are not going to fill opioid prescriptions. 

The environment has created fear from scrutiny from medical boards, DEA, and insurance companies intervening and telling the physician how much medication a patient can receive. Pharmacies are refusing to fill prescriptions. 

What can we do? I propose that we maintain a doctor-patient personal relationship. Cases must be evaluated individually, not as an overall group policy. An explanation and discussion with the patient on collaboration and support is mandatory.This should include implementation of alternative therapies. We follow the dictum of “Do No Harm.” In many instances, it is certainly harmful to tell a patient, “I am going to stop your medication,” knowing that withdrawal will occur. The pendulum has swung too far regarding maintaining appropriate patient care. 

Michael S. Parr, M.D., F.A.S.A.M.
Board Certified in Addiction Medicine