A patient’s plea for pills masks the need to quit
Prescription refill. A simple request -- usually satisfied in a brief visit by taking pen to pad after reviewing symptoms, course, side effects and progress toward stability, recovery or cure.
Sitting on the edge of his chair and drumming his fingers on my desk, Tom told me the dose and number of pills he expected and clearly indicated that he thought my inquiries into his medical history were a waste of time.
Yes, he’d had back and neck pain for months and, no, nothing else worked, not over-the-counter pain medications, orthopedic consultations, physical therapy or chiropractic treatment. A returning student, he had a critically full plate, juggling a demanding career and an intensive degree program, and insisted that only hydrocodone -- his sixth prescription -- would allow him to finish his education before he ran out of funds.
Faced with Tom’s continuing complaints of pain, his previous physicians had given him prescriptions for a strong and frequently habit-forming medication, a short-acting pain fighter in the opioid family.
The pill relieved his pain and allowed him to keep up his feverish pace, but led to his dependence on the medication to function. Over the last few months, Tom had begun to take almost double the recommended dose. An ambitious achiever, he had tried to control his pain and maintain his performance with hydrocodone. Instead, the hydrocodone had taken control of him.
Chronic pain can be disabling -- research has shown it can negatively affect emotional, psychological and physical well-being. Many sufferers make frequent visits to health-care providers, hoping for relief, and some self-treat with more frequent doses of pain pills than advised, become dependent on the pills and then shop among doctors for one or more physicians who will dole out the next “fix.” Online Internet prescription options make drug purchases even more convenient.
As underscored by recent admissions from Rush Limbaugh, the very real problem of chronic pain may become compounded by an evolving drug dependency and addiction.
To his dismay, I told Tom that I was deeply worried that his health was being compromised, and that I could not write a new prescription to “get him through” the next few months until his graduation.
We then discussed a number of steps necessary for his recovery. First, he would need a reevaluation by his orthopedist to determine whether he had structural damage to his spine, nerves or muscles that could be treated medically or surgically. An ergonomic evaluation, I added, could determine whether his work habits and environment might be changed to reduce muscle strain and overuse injuries. Tom also would need another check of his general health to rule out any underlying disease such as arthritis that could cause or aggravate his symptoms.
Most important, I told Tom, it was critical that he see a pain medicine specialist to chart a treatment plan, which could include safer and more effective medications if needed, as well as counseling to address emotional and lifestyle factors such as stress and diet that might contribute to pain. I strongly recommended that Tom begin to trim his hydrocodone use and his work schedule and, recognizing that taking these steps would be a difficult challenge, I also referred Tom to resources for obtaining financial aid and academic support.
Tom’s irritation and impatience had masked his growing concern about his drug dependence. After our frank discussion, Tom acknowledged his relief at facing his hydrocodone use and expressed his willingness to embark on a supervised treatment program.
By the time graduation day arrived, Tom had stopped using hydrocodone. With the help of continuing counseling and physical therapy sessions, supplemented by occasional use of nonprescription pain medication, Tom was relatively pain-free and back in control of his life.
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Dr. Linda Reid Chassiakos is director of the Klotz Student Health Center at Cal State Northridge and a clinical assistant professor of pediatrics at UCLA.