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.
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.
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.