The Pain Medication Conundrum

Danielle Ofri, an associate professor at N.Y.U. and a physician at Bellevue Hospital, is the author of “What Doctors Feel: How Emotions Affect the Practice of Medicine.”

MY patient Mr. W. wheeled himself into my office for a checkup. He’d lost a leg to diabetes and was also juggling hypertension, obesity, vascular disease and elevated cholesterol. He was an amiably cranky fellow in his mid-60s who’d used heroin in the past though had been clean for decades.

As we finished up and I handed him his stack of prescriptions, he said, “Oh, by the way, Dr. Ofri, I was wondering if you could prescribe me the oxycodone I use for my back.”

Oxycodone? In the six months I’d known him, I hadn’t been aware that he was taking narcotic pain medication.

“I’ve been getting it for years from my pain doctor in the Bronx, but that clinic closed,” he explained. “So now I’ve got to get it from my primary care doctor.” …

What are doctors to do? Pain is a subjective symptom. There is no instrument to indicate its severity. All that a doctor has is the patient’s word.

For patients with chronic pain, especially those with syndromes that don’t fit into neat clinical boxes, being judged by doctors to see if they “merit” medication is humiliating and dispiriting. It’s equally dispiriting for doctors. This type of judgment, with its moral overtones and suspicions, is at odds with the doctor-patient relationship we work to develop.

As Mr. W. and I sat there sizing each other up, I could feel our reserves of trust beginning to ebb. I was debating whether his pain was real or if he was trying to snooker me. He was most likely wondering whether I would believe him or if I would be biased because he was an African-American man with a history of drug use. Studies show that minorities are consistently undertreated for pain…

A solid doctor-patient alliance is a critical factor for good health. But when patients feel judged by their doctors, and doctors are exhorted to not undertreat pain and simultaneously pilloried for overprescribing pain meds, this relationship can be sabotaged. That isn’t good for anyone’s health.

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