Author: Douglas L. Gourlay
Dr. Heit: Inherited patients usually come in with certain pharmacotherapy and you have to decide after your history and physical whether that pharmacotherapy is irrational or rational. Is it pharmacotherapy that you feel comfortable prescribing and continuing without change? Is it pharmacotherapy that you’re comfortable prescribing with a little bit of tweaks or is it pharmacotherapy that is completely unacceptable? With the woeful lack of teaching in pain medicine and addiction medicine, many doctors have an entrance strategy, how to get somebody on pharmacotherapy but have no idea of an exit strategy.
Dr. Gourlay: The inherited pain patient is really one of our greatest challenges in medicine because even if their pattern of pharmacotherapy is irrational, the vast majority only got there with the help of a physician, and I think we owe a special duty of care to patients who have iatrogenetically come to harm. Then unfortunately, many patients find that the physicians who are charged with taking care of them are either ill-equipped or unwilling to address the problem with anything other than simply discontinuation of the drug. Change is a process. Notwithstanding what Howard said, if you have something that’s either what you would do or what you can live with for a period of time, giving the patient that opportunity to develop a relationship with you can make the difference between success and failure.
Dr. Heit: Medical care should be compassionate, defensible and should be rational. It all is part of the holistic treatment of the patient. Especially in pain management, you can’t just treatment one part of the body. You have to treat the person in a biopsychosocial model. Is there depression present, is there any anxiety present, bipolar disease, ADD, history of sexual abuse, physical abuse? They all go in to making up the patient. You can’t focus yourself just on one piece of the pizza pie. You’ve got to take care of the whole patient.And always document, document, document. If you don’t document what you’re doing in the medical/legal chart, it’s a figment of your imagination. It’s both to protect yourself, the patient, and to memorialize what you’re doing in a record.
Dr. Gourlay: Ideally, a medical record should allow a knowledgeable individual to review it and come to a reasonable conclusion as to what you did and why you did it. There should always be a logical reason for dose increases, dose reductions, why you’ve ordered in a lab test such as a urine drug screen, what information you obtain from it, and ultimately, what course correction, if any, that you felt was necessary including staying the course.
One of the things to remember about opioid tapers or medication tapers in general is if they’re drugs which are agonist in quality, in nature, they are likely to produce some degree of physical withdrawal. In some cases, it’ll be greater or lesser depending on the individual in their past experience; but it’s a myth that if you go slow enough, you can eliminate withdrawal in everybody. The reality is you can mitigate withdrawal. You can certainly worsen it by a poorly thought through taper, but if your goal is to get off the medication, then it should be kept in mind as you adjust your taper in order to be sensitive to the fact that the patient needs time to neuro-adapt. The brain is expected to adapt to the lower medication level, but it shouldn’t be so long a process as to extend the misery needlessly.
Dr. Heit: One final point, I think that it has to be known that if I’m going to taper you or wean off opioids, it can be difficult but it’s more difficult to taper/wean somebody off a benzodiazepine. Patients will have generally a harder time getting off benzodiazepine than they will off an opioid even under the best taper possible.