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Opioids Addiction and Chronic Pain

Jul. 12th 2018

Nearly every day there is another story in the news about the tragedy of addiction in America. Much of the focus on this deadly disease is on opioids. Addiction and overdose results in tens of thousands of deaths annually in the United States. Many of these addicts aren’t just taking opioids. They often overdose on combinations of drugs. The medical term for ingesting multiple medications is, polyphamacy and it’s found in the majority of overdose deaths. Anxiety drugs from the Valium, Xanax family, benzodiazepines, are particularly dangerous. Opioid overdose results in respiratory depression, dangerous slowing or stopping of the breathing reflex, so taking too much, especially with other sedatives is a death sentence. America’s problem with addiction, focuses on opioids, the leading actor in this complex tragedy. Addiction is not new to mankind but our substances today, like all aspects of our hectic lives, are on overdrive. Prescription opioids have given way to heroin and criminally produced synthetics like fentanyl derivatives which now are the leading opioid killers. The opioid story is not a simple one. These potentially dangerous drugs are also important in the treatment of one of the most important medical disorders in America. Chronic Pain.

It is rare to hear anything about chronic pain in the opioid debate. Chronic pain has many causes . Accidents, surgeries, congenital disorders, degenerative spine and joint disease, headaches. Doctors recognize the impact of daily pain and see patients with it every day. The scope of chronic pain is staggering. Pain contributes to stress and other diseases including cardiovascular disease and mental illness.

Chronic pain is responsible for trillions of dollars in lost wages, medical treatments, and disability payments. While the financial impact of chronic pain is staggering, it is the suffering and misery that it brings to individuals and families that is most significant. Nearly one out of every three Americans suffer from some form of chronic pain. If you don’t have it, you know someone who does. Not everyone is miserable, but millions struggle. Chronic pain can’t be cured or fixed. It’s sufferers have more depression and other mental illness. It ruins marriages, destroys families, breaks up friendships and keeps people from being productive at work and at home. Unmanageable pain can lead to suicide. Pain is a physical problem, but it is far more than that. It is a truly biopsychosocial, spiritual problem. It robs the sufferer of the joys of life. Pain steals by preventing us from doing. It’s not just that we hurt, its biggest challenge is how it prevents us from doing what we want and need to do.

There’s more bad news.

Though we have come a long way in finding useful treatments to help manage it, we are lousy at treating chronic pain. It is often very difficult to diagnose precisely and it is usually not associated with the words “cured”, “fixed” or “healed.” Pain specialists use the word “manage”, a term that many patients will never accept or agree with. Living with chronic pain is often a life-long chore, and like other chronic illnesses it needs ongoing management. Finding someone to help with this incurable disorder isn’t all that easy. Treatments for chronic pain are best broadly focused or “multidisciplinary”, a loaded medical word that means you have to Do lots of things to get it controlled. Most important are self motivated activities, such as exercise and finding ways to keep moving, avoid painful triggers, and get engaged in diversionary activities to get your mind right. There are also passive treatments available like massage, acupuncture, injections, nerve stimulators and implantable devices, manipulations and other therapies that help some but don’t cure. Having a compassionate support system is critical. If you like clean problems with fixed answers, don’t pursue a career in chronic pain management. One other thing, chronic pain also can’t be cured or fixed with pills.

So back to opioids. How did they become public villain #1? The 30-40 year history of the rise of opioids in medicine is a long fascinating story. Though opioids have been around since antiquity and used by doctors to treat pain for centuries, chronic pain wasn’t widely treated with opioids until about 1995. New drugs like OxyContin and patch fentanyl were released around the same time that respected physicians began talking about benefits of using opioids over a long term to treat pain. Doctors and pharmaceutical companies clearly got the early stages of this opioid rollout very wrong as we began to use them for chronic pain suffers in the mid 1990s. We were lead to believe that high opioid dosing didn’t matter. Big pharma made sure there was a lot of drug out there for good but there was not enough attention to the potential for bad. They pushed pushed their products with vigor and carelessly. Bad science was touted as good and Doctors were fooled. Pharmacies were later sued and paid large settlements. We asked patients to score their pain with a 0-10 pain score, which is the worst monitoring tool for chronic pain ever devised, yet we continue to use it to adjust medication. You can’t try to lower chronic pain with a simple number system. The use of the 0-10 pain score in my opinion. Has done far more harm than good and has helped create the problem of overprescribing to chronic pain patients .

With the prescribing problems however, we also learned something else very important. They worked. Many many of our patients were much better on reasonable doses of opioids. For this large group of patients, the medications were doing exactly what we had hoped. They lowered pain intensity, and made people feel better. For this group with successful management, they didn’t cause excessive side effects, didn’t create a tolerance to the pain relieving effects as they relieved pain and suffering. These patients also didn’t behave like addicts. Yes, they needed the medication, but not like an addict did. They needed it like patients with high blood pressure. If they didn’t take it, their disease got worse again, i.e. the pain intensity came back. In that sense we used the term dependent, not addicted. The relief and improvement was dependent on the daily use of the drug. Patients got some of their lives back. They also improved psychologically.

Most good doctors recognized early on that, like other drugs there was a big risk/benefit in prescribing opioids. This isn’t unusual. Doctors deal with this with nearly every medicine.
Few people are aware that there may be 16,000 deaths annually from the use of Non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen, drugs purchased over the counter. The risk from these drugs is even higher in the elderly who are at risk from GI, renal and cardiac complications. NSAIDS and other drugs however, kill slowly.

Opioids in the hands of an addict kill more dramatically and suddenly. Young people are also more prone to addiction, lives ruined and destroyed early, suddenly, make an impact. Addicts ramp up the problem by doing what addicts do, lying , stealing, selling medicines and doing whatever it takes to get more drug. Overdose is front page news and dirty work in the ERs and on the street.

Still, in the midst of all of the bad, there were patients being helped, lots of them. Elderly patients who stopped crying all day, fathers who went back to work. Depressed patients that suddenly had some hope that their lives would’t be lived in persistent pain found their depression lifted. These examples were far more prevalent than many people realize. It proved to Doctors that opioids had a place in the management of chronic pain. The question was how to mitigate risk. How could we continue to use opioids smarter to decrease the risk of addiction and the horror of overdose.

We still have a lot to learn but we are getting smarter. Practices have been changing broadly. We are following guidelines that make prescribing more uniform. We are closely screening, monitoring and educating our patients. We Are limiting doses to levels that appear to be safer. We are working with pharmacies and insurance companies to keep a watchful eye on prescriptions.

Sadly though we are also seeing many physicians completely abandon opioids altogether, some even claiming that it’s not their job to treat pain, a problem one out of every three of their patients suffer. The fear of doing it wrong and being blamed is understandable. A knock on the door from the DEA scares doctors a lot. There have been doctors who essentially sell prescriptions with clear knowledge that they were serving addicts not treating pain patients. The appropriate focus is on those drug dealing physicians, not on legitimate prescribing with intent to help manage chronic pain. Doctors need support to make sure that their intent and practice allows them comfort in doing the right thing. We need to provide better support and treatment for those who develop addictions to opioids yet we also can’t pull these vital medications away from patients whose lives have been dramatically improved by their use.

The answer to the opioid crisis is challenging. Opioids remain one of the most valuable tools we have in the management of chronic pain. We must pledge to carefully use them, to continue to study and learn more about them and apply the knowledge and experience to our practice. Our suffering pain patients deserve nothing less.

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Drug Soup and Doctoritis

Aug. 8th 2016

The current opioid crisis requires pain specialists to use caution and navigate carefully when prescribing pain medications.   Along with opioids we are often faced with another medication problem that we are seeing more frequently.     I’ve taken to calling this drug soup.   Medications that work in the central nervous system (CNS) and alter brain chemistry are being prescribed for every imaginable symptom.     Since patients frequently see more than one doctor, they often get different centrally acting drugs from different prescribing physicians.  We are often consulted to be in this group of specialists.   In a situation with multiple prescribing physicians I often use the term “too many cooks in the Kitchen” or “doctoritis”.   I am uncomfortable being part of doctoritis but many times we’re in the mix.

There are some patients that expect a pill for every one of life’s problems.   Pain, depression, stress, anxiety, insomnia, lethargy, lack of energy, lack of concentration and grief are all common complaints that physicians hear about daily. There are pills to address all of these symptoms and believe me, some patients have them all!   In addition to opioids, there are antidepressants, muscle relaxants, nerve pain medications like gabapentin and non-narcotic pain meds.   In addition there are stimulants for ADHD and there are sedatives and sleeping pills to shut people down.   It is not unusual for us to see a new patient to show up in our office with 7 or more “centrally acting drugs” on their daily list. DRUG SOUP! This doesn’t include the medications taken for heart disease, diabetes, asthma and other medical conditions.

We are a pill popping culture.   This drug soup occurs gradually over time but if you try to simplify these regimens, you‘re often messing with medications prescribed by another physician. It can be a delicate situation to change someone else’s treatment plan.

Patients on this many drugs are often not doing well, that is why they show up in a specialty pain clinic. It is no surprise that the drug interactions are unpredictable and dangerous.  Despite discussing this at length I also often find reluctance from patients on drug soup to simplify their regimen.   The reasoning and logic is generally along these lines, “if I don’t feel good taking all these drugs to make me feel better, then I’ll surely feel worse if I stop one.”   That thought is deeply ingrained.     Reducing central acting medication loads is a slow process of tapering and requires full patient buy-in or else it’s doomed to failure. Alternatives to pills need to be part of the conversation.

America loves to find a villain for every problem.   Right now, opioids are taking all the heat for drug overdose and addiction. That’s a real problem and it must be addressed, but in my opinion, DRUG SOUP and the desire to take a pill for every one of life’s challenges is another huge problem that needs our attention.

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IV Hydromorphone

Feb. 19th 2016

In 1979 during my psychiatry rotation in medical school I was sent to the Methadone clinic in Kansas City. I still remember talking about drug addiction with the clients.   One comment stuck with me.  A guy trying to stay clean told me “If God made anything better than IV Dilaudid, he’s keeping it for himself!” That was the first time I had ever heard of the drug Dilaudid.

Dilaudid is the trade name for hydromorphone, an opioid in the morphine family. It has a rapid onset and a short duration. Because it’s effects are rapid it has benefits to quickly bring pain under control. It can be given by mouth or IV. It is a VERY good pain reliever and if given as an IV bolus (quickly through the the IV) pain will drop rapidly and dramatically.  There is often a sense of warmth, well being and calm, for first time users euphoria is often described. These IV effects are a lot like the effects of another opioid, heroin. One more thing, it wears off quickly and the pains comes back often with a vengeance leaving the suffer begging for another shot.
IV hydromorphone  Has now become the choice  IV medication for severe 10/10 reported pain in many ERs and in hospital patients. Patients like it and learn its benefit. Many ask for it by name. A poor fellow we saw this week had been getting it for 4 days every three hours on the clock for an amputated toe.  He was angry with the nurses if it wasn’t given right on time. It was the ONLY thing that worked for his terrible amputation pain. When I was consulted I told him that this was learned behavior, his brain now trained to only get relief from an IV bolus of a strong narcotic. In laymen terms I explained why this was a bad thing and he got angry with me also. I spent a lot of time trying to educate him on the longer term consequences of this brain training. He wasn’t interested. Although I addressed the phenomenon as addictive behavior I was careful not to directly label an angry guy as an addict. He only sees himself as a miserable pain patient. I have tried telling new patients on a first visit that they’re an addict. I usually get tossed out of the room.  Since I was asked to help with the case,   I stopped the IV bolus as a first step and put him on an oral medication similar with slower onset, less rapid effects and also added a non-narcotic coanalgesic to help with nerve pain. This would prevent withdrawal but would begin to change his need for the IV effect. He requested that I be taken off his case (I was fired) and the next day he was back on IV Dilaudid again.
This is addiction and clear addictive behavior albeit in a miserable guy with  pain.  He has had experience with chronic pain.   Reversing this learned behavior is not easy, and we are not helping patients when we use these excellent pain killers for too long. In acute settings like the hospital it may be useful to apply these powerful tools, but managing them to prevent addiction is important. Not all patients recieving IV opioids become addicted, but this is one example of how we have created drug addicts in our efforts to be compassionate about pain.  If we truly care about our patients we will also need to spend time explaining why we are not giving them what they want. Most who have received this discussion understand and are agreeable to changes that will prevent further harm and the risk of addiction. Unfortunately there are many who reject the information and are angry. This denial is also a sign of addiction. We have to be smarter about using our best pain relievers and that sometimes means being the bad guy to help our patients.
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Stress

Jan. 12th 2016

Nearly everyone I see in the clinic talks about stress.    Certainly the challenges of facing serious illness and dealing with chronic pain  can generate tremendous fear and anguish.  This stress has no socioeconomic borders.   Winning the billion dollar lotto won’t eliminate stress related to illness in fact, stress even overwhelms many people without health or financial problems.   It appears that humans are hardwired to seek out threats and to chase what we want so aggressively that we can’t escape the constant worry about our unresolved issues.    It is amazing how many people with chronic stress try to manage it with tobacco, alcohol, drugs and America’s favorite, food.    Those approaches don’t work.       I have been a student of stress and ways to combat it for a long time.   Much of it is for personal reasons but it is also important in the overall physical and emotional  “wellness ” we preach in the clinic.      I have two books going, one a gift,  and also one “great course” lecture series I’m finishing.  All address ways to understand how our minds work creating stress and how we can combat it.    The Great Course lecture series is Professor  Mark W. Muesse  “Practicing Mindfulness: Introduction to Meditation” .    Mindfulness Meditation with Buddhist philosophy  is a well studied form of meditation that has been popularized in the west by Jon Kabat-Zinn from the University of Massachusetts who has also authored many books related to stress, pain and illness.   I’m really enjoying “The Guide to Stress Free Living” by Amit Sood M.D M.Sc. . from the Mayo Clinic.    He looks into brain research to better understand how our brains work and focuses on practicing gratitude, compassion and acceptance as ways to manage stress by in a very outward fashion.  While the book acknowledges and respects  religion and faith traditions that also promote these ideals, it is a secular approach anchored in science that makes his book accessible to nearly everyone.    Last night I started “10% Happier” (How I tamed the voice in my Head, reduced stress without losing my edge, and found self-help that actually works-A true story)  a New York times Bestseller by Dan Harris.   My wife gave it to me for Christmas….she knows me too well.      There is no shortage of resources out there, these are only a few.   I would encourage everyone to look into ways to manage stress in a healthy manner.  As Soot says; ” it will help you live a meaningful life, cultivate nurturing relationships and achieve your highest potential.”   Oh yeah,  it helps you manage pain as well.     RLM

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The unplanned journey

Sep. 3rd 2015

When I set up this website a couple of years ago I envisioned that I might be blogging with some regularity, not daily, but at least more often than once a year!   I’m going to give it a go again with a post here and there and I hope my partners will also occasionally post.   There is so much going on in the world of pain management and palliative care that it begs for some thoughts from physicians who practice in the arena daily.     Like many blogs, these will be editorial thoughts for what they are worth.   If nothing else, I hope they will spur thought, conversation and perhaps controversy!

As we took off on rounds this morning we were discussing the man we were about to see. He is clearly at the end of his life, but not actively dying. It is here where palliative care seems to be most important.     Heart disease. Lung disease, diffuse spinal degerative disease, morbid obesity. He is immobile and now has a potentially lethal spinal injury with infection that cannot be “fixed” or even stabilized by surgery. He’s an older man, in his late 70s close to the average for life expectancy in the USA. He has been slowly declining and really is suffering despite everything we can throw his way to help with physical pain.    Without a DNR and with family members resistant to the concept he is facing a rough end.   It’s been presented but family is not ready to discuss it.

This is a little like someone who decides to take a trip, and has booked an airline flight.  They have no other plans.   They aren’t even sure which country their plane will land in.   No planned place to stay, no travel itinerary, they’re not sure how to get back or how long they’ll be there.   No one would take that trip yet we see this thinking in the hospital often.   People seem willing to accept medical care without even spending time to discuss thoroughly what that trip will look like.   This gentleman has a good chance of ending his life on a ventilator with a feeding tube in a facility, bedfast, if he survives a code blue and makes it through the ICU.    It’s his choice but he and his family deserve the right to have more than one travel itinerary presented to them before his plane takes off and lands.

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Treating Chronic Pain

Jan. 8th 2015

Chronic pain is a challenging condition that is estimated to affect 15 -20% of the adult population of the United States.    One of the most critical questions about any specific treatment for chronic pain is, “does it work?”   The answer to this simple question is complex and with all honestly, “it depends”.     This sort of answer really upsets academics and payers when we try to devise strategies to treat pain. In medicine we want our treatment plans to be based on evidence-based medicine (EBM).   The idea here is that modern medicine can predicted best treatment by plans that have been established by good research data.   The best form of this research is called a double blind, randomized controlled trial (RCT).    Unfortunately the challenges in using evidence based medicine approach and creating good randomized controlled trials are massive particularly in pain management which has so many variables. Just a few of these involve unique Injuries and pain generators , personalities, upbringing, expectations, support systems, psychological and emotional stressors, co-illnesses, access to care, not to mention a payer system which has every patient playing by a different set of rules.

Don’t get me wrong, we’d love RCT with EBM to direct all our treatments, but they aren’t there.   Many advertised treatments report that they have been successfully studied, but most of these claims are based on limited data and often not the gold standard research discussed above. Pain specialists are called on to help in difficult cases.   We are in not in the position to simply turn patients away after some Tylenol, a couple of NSAID trials, an anti-depressant and some expensive medications that have high side effect profiles that half our patients can’t afford.

We have some treatments that work well, but all treatments don’t work the same for every patient even with similar diagnosis. .   We use our experience and knowledge to find what helps but unfortunately many restrictions often block our efforts.   More restrictions seem to be on the way.    Using trials of therapy has been our approach.   The key to treating pain successfully is to take excellent history, examine the patient, review the available studies, order new ones when appropriate then start trying the safest treatments most likely to help.   We also must be ethical and cost conscious.      If the initial treatments are not successful a different treatment must be trialed.    There may be a time when we can neatly wrap all this into a fixed plan that makes payers and academics happy but we are a long way from that ideal.   The skill and experience of   physicians must be respected in this endeavor or our patients will lose out on many successful treatment options.

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Opioids and Chronic Pain Shifting Sands

Aug. 27th 2014

This letter went out to Physicians at St. Joseph Medical Center August 27, 2014.   It’s a little long for a “blog” but here it is:

Opioids and Chronic Pain: Shifting Sand

The FDA has reclassified Hydrocodone from a Schedule III opioid to Schedule II and Tramadol has become schedule IV.  The use of opioid medication for chronic non-cancer pain remains the most controversial topic in pain management.  “Opioid” is the proper term for all medications natural and synthetic that have a narcotic action similar to morphine.       We now have a dizzying array of opioid medications available to treat physical pain.   Drugs vary in many ways, including onset, duration of action, opioid receptor preference and affinity.   Some available drugs are pure opioids such the schedule II opioids morphine, Hydromorphone Oxycodone and Fentanyl. Hydrocodone, which has only been available as a combination medication with acetaminophen and occasionally ibuprofen, has been available up until now as Schedule III.   Prescriptions for Hydrocodone as a schedule II will no longer be available with refills and can not be called in by phone.  

   In the last 20 years we have seen a pendulum swing. Prior to 1990 there were very few physicians who advocated for the use of opioids to treat chronic pain conditions.   That all changed in the 1990’s and 2000s when we saw a tremendous increase in the use of opioids for non-cancer pain.   Much of this was spurred by small clinical studies and many anecdotal reports describing efficacy. In addition, many physicians and nurses worked to make pain management a priority and advocacy groups also joined in lobbying for more liberal access to opioid pain medication.   The Federal Joint Commission pushed the issue by mandating pain management for hospital accreditation.   Big Pharma moved in and filled the need with more variety and promoted long acting, rapid acting and highly potent pain killers.    

 While many will point to the improvements in helping millions of suffering patients, the highly publicized bad outcomes and serious problems have made lots of headlines.   Addiction, fatalities, drug misuse, abuse, tolerance, physiologic and psychological dependence have increased in step with the increase in prescribing.   Bad prescribing, poor patient selection, lack of patient education and poor patient compliance to established plans are just a few of the causes for these bad outcomes.   The pendulum is swinging back and it seems physicians are less willing to prescribe opioids for patients with chronic pain.

 While pain advocacy groups talk about physician’s fears of personal prosecution as the cause for this reluctance to prescribe, I think there are more compelling reasons.   Most physicians that I talk to who are reluctant to prescribe opioids simply feel that risks out weigh benefits and it’s the wrong way to treat patients. They are also uncomfortable with the complexities of prescribing regimens, drug choice, follow-up and long term management issues.

Opioids remain important and valuable drugs.   They have great potential to provide improvement in quality of life and well being for properly selected AND properly managed patients.     What we have learned from the last 20 years is not surprising.   Opioids are dangerous drugs and can also cause harm.     This is no different from many other medication classes but the association with addiction places them in a clearly different category.   We are now also worried about Acetaminophen and liver failure, NSAIDs with GI, Renal and cardiovascular risks, and tricyclic antidepressant medications due to anticholinergic and sedating side effects.   As for opioids, we continue to study and learn more about best practice in prescribing these important drugs.   Ignoring them or refusing to use them denies many patients much needed relief from unrelenting pain.   We must continue to be vigilant and use caution in prescribing all these medications as we learn more.  

The reclassification of Hydrocodone and Tramadol will not eliminate problems and it will make it harder to initiate opioid therapy. It sends another message to physicians and patients alike that opioids are dangerous.     It will result in a decreased access to opioids for chronic pain.   Time will tell what this swing of the pendulum will bring for patients who suffer from intractable pain especially at time when many other treatments for pain are also under scrutiny.                  

RLM 8-27-2014 

 

 

 

 

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Remembering

Jun. 12th 2014

I just had a remarkable conversation with one of the most stoic dying gentlemen I’ve ever met.  He has been calmly going about making plans for his remaining days both in regards to his physical life and stuff, as well as saying goodbye to the people he loves and preparing spiritually.   He told me a story today about his own father’s funeral.  One of his father’s admirers tapped him on the shoulder as they were leaving the church and slipped a cassette tape of his father’s service in his pocket.   I at first found this to be maudlin, but then thought of my own father’s funeral.  I remembered the beautiful eulogy given by his friend and long time work partner and how moved I was by his words. I’d always wished I’d asked him for his notes.     Most funerals are celebrations of life.   We tape other celebrations, weddings, baptisms, birthdays.  The funeral of a loved one may be difficult to relive for those closest to them but for the next generation it is a wonderful way to share the details of a beloved ancestor.

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Resources for Seriously Ill patients and their families

Apr. 11th 2014

One of the hardest things we will all likely face is the challenge of dealing with the medical system at the end of life. It has become complicated in every way. The care is complex, the decisions are overwhelming and agonizing. There are usually multiple providers and physicians (not to mention family and friends) each with opinions and counsel. The reimbursement system for health care has been a mess America for a long time. Who understands it? We see patients and families struggle with these issues every day. I’m rereading “Horse and Buggy Doctor” written in 1938 by Arthur E. Hertzler a small town Kansas doctor. It’s about his medical practice in the first part of the 20th century. It makes me appreciate the good things we have and how fortunate we are to live in America at a time when so many things can be done to treat disease and injury. Nonetheless, finding the best care possible today is not an easy task. The “best care” is not always the most care! Books I often recommend are: Ira Byock’s “Dying Well” and Joanne Lynn, Joan Harrrold, and Janis Lynch Schuster’s ” Handbook for Mortals” All of these books are available on tablet. (even Hertzler’s!) They are not exactly beach vacation reads but I hope they serve as useful references when needed.

RLM  (4/30/2014)

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Challenges in prescribing

Apr. 2nd 2014

The treatment of pain with medication is one of the most challenging tasks our physicians must perform. It requires knowledge of pharmacology, experience, patience and courage! Courage, because medicines routinely cause side effects, have toxicities, and may fail at their intended purpose. There are risks of interfering with medication plans or philosophies of referring physicians. In addition, prescribing pain medication is apt to be judged and second guessed by family, colleagues, insurers, regulators and attorneys. Strong opinions abound! At times medications are inappropriate and the refusal to prescribe under patient pressure can also require courage. Medicines must be chosen for their merits, prescribed with a proper plan, at the proper dose, for the proper amount of time with an eye on consequences. Physicians and patients must also deal with the frustrations of cost, insurance plan coverage restrictions, preauthorizations and other obstacles to the use of many medications. Good medication management requires education, monitoring and modification. Patients and family must be made aware of all these important considerations. With good and careful trials, timely follow up and patience we are often able to establish excellent medication plans to help our patients.

RLM. (3/26/14)

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