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Patients in Pain, and a Doctor Who Must Limit Drugs
By JAN HOFFMAN
MARCH 16, 2016
MILFORD, Neb. — Susan Kubicka-Welander, a short-order cook, went to her pain checkup appointment straight from the lunch-rush shift. “We were really busy,” she told Dr. Robert L. Wergin, trying to smile through deeply etched lines of exhaustion. “Thursdays, it’s Philly cheesesteaks.”
Her back ached from a compression fracture; a shattered elbow was still mending; her left-hip sciatica was screaming louder than usual. She takes a lot of medication for chronic pain, but today it was just not enough.
Yet rather than increasing her dose, Dr. Wergin was tapering her down. “Susan, we’ve got to get you to five pills a day,” he said gently.
She winced.
Such conversations are becoming routine in doctors’ offices across the country. A growing number of states are enacting measures to limit prescription opioids, highly addictive medicines that alleviate severe pain but have contributed to a surging epidemic of overdoses and deaths. This week the federal government issued the first national guidelines intended to reduce use of the drugs.
In Nebraska, Medicaid patients like Ms. Kubicka-Welander, 56, may face limits this year that have been recommended by a state drug review board. “We don’t know what the final numbers will be,” Dr. Wergin told her, “but we have to get you ready.”
As politicians and policy makers decry the opioid crisis, the country’s success in confronting it may well depend on the ability of physicians like Dr. Wergin to reconcile their new role as enforcer with their mission of caring for patients. Collectively, primary care physicians write the greatest volume of opioid prescriptions — according to a recent study, 15.3 million prescriptions for Medicare patients alone in 2013. The burden of monitoring patients for potential abuse, while still treating pain that is chronic and real, falls largely on these front-line gatekeepers.
“I have a patient with inoperable spinal stenosis who needs to be able to keep chopping wood to heat his home,” said Dr. Wergin, 61, the only physician in this rural town. “A one-size-fits-all prescription algorithm just doesn’t fit him. But I have to comply.”
In prescribing opioids, Dr. Wergin, who is also chairman of the board of the American Academy of Family Physicians, is taking professional and personal risks. He must go through an elaborate prescription checklist, with state and federal officials looking over his shoulder. He has faced threats from addicts who show up at the hospital emergency room, desperate for pills. Following the recommendation of his malpractice insurance carrier, he now requires his patients to sign “pain management contracts,” in which they must agree to random drug tests before receiving an opioid prescription.
Cont with many photos http://www.nytimes.com/2016/03/17/health/er-pain-pills-opioids-addiction-doctors.html?_r=0
By JAN HOFFMAN
MARCH 16, 2016
MILFORD, Neb. — Susan Kubicka-Welander, a short-order cook, went to her pain checkup appointment straight from the lunch-rush shift. “We were really busy,” she told Dr. Robert L. Wergin, trying to smile through deeply etched lines of exhaustion. “Thursdays, it’s Philly cheesesteaks.”
Her back ached from a compression fracture; a shattered elbow was still mending; her left-hip sciatica was screaming louder than usual. She takes a lot of medication for chronic pain, but today it was just not enough.
Yet rather than increasing her dose, Dr. Wergin was tapering her down. “Susan, we’ve got to get you to five pills a day,” he said gently.
She winced.
Such conversations are becoming routine in doctors’ offices across the country. A growing number of states are enacting measures to limit prescription opioids, highly addictive medicines that alleviate severe pain but have contributed to a surging epidemic of overdoses and deaths. This week the federal government issued the first national guidelines intended to reduce use of the drugs.
In Nebraska, Medicaid patients like Ms. Kubicka-Welander, 56, may face limits this year that have been recommended by a state drug review board. “We don’t know what the final numbers will be,” Dr. Wergin told her, “but we have to get you ready.”
As politicians and policy makers decry the opioid crisis, the country’s success in confronting it may well depend on the ability of physicians like Dr. Wergin to reconcile their new role as enforcer with their mission of caring for patients. Collectively, primary care physicians write the greatest volume of opioid prescriptions — according to a recent study, 15.3 million prescriptions for Medicare patients alone in 2013. The burden of monitoring patients for potential abuse, while still treating pain that is chronic and real, falls largely on these front-line gatekeepers.
“I have a patient with inoperable spinal stenosis who needs to be able to keep chopping wood to heat his home,” said Dr. Wergin, 61, the only physician in this rural town. “A one-size-fits-all prescription algorithm just doesn’t fit him. But I have to comply.”
In prescribing opioids, Dr. Wergin, who is also chairman of the board of the American Academy of Family Physicians, is taking professional and personal risks. He must go through an elaborate prescription checklist, with state and federal officials looking over his shoulder. He has faced threats from addicts who show up at the hospital emergency room, desperate for pills. Following the recommendation of his malpractice insurance carrier, he now requires his patients to sign “pain management contracts,” in which they must agree to random drug tests before receiving an opioid prescription.
Cont with many photos http://www.nytimes.com/2016/03/17/health/er-pain-pills-opioids-addiction-doctors.html?_r=0
