Thread by @TNREthx

I had a really interesting conversation with a pain doc. He had read some of my work and wanted to chat. Despite his basically confirming what I know, I can’t shake how DARK his knowledge of pain care is.

Thread.

I’ve argued that we have to be careful of chilling effects on prescribing—not only for new patients but for patients already dependent on opioids. In his state, the chill is complete. Even as a pain doc, there is significant risk for taking on any patient on high dose opioids.

If he does take them on, he has to immediately taper them, so he can tell the inevitable medical board investigation that he’s ‘doing the right thing’. But most of his colleagues simply won’t accept high dose patients.

Further, he sits on a review board to evaluate suspicious cases, and has seen what it costs docs who are sympathetic to high dose patients. One doc quit prescribing, leaving all his patients one month to find someone. Another doc took them all on, bc no one else would.

Who got investigated? Not the doc who abandoned his patients of course; the good doc who took them on, preventing massive suffering. My new friend’s commentary: “I’m sure that guy won’t ever take on another high dose patient again.”

This isn’t news to many pain patients and researchers. We know this is happening some. But the clear knowledge this guy has that in his state, this is the RULE, not the exception—it’s awful. And everyone who knows me knows I’m not ‘pro opioid’ (or anti opioid for that matter).

But I am PRO COMPASSION. I’m also pro care, pro patient-centered medicine, and pro responsible prescribing. When regulators essentially legislate unnuanced practice, it tends to have harmful, unintended consequences. We’re seeing some of those now.

In short: the situation described to me in pain medicine in one particular state (and likely many others) is absolutely unjustifiable. We don’t get to abandon or torture patients in an ill-advised attempt to solve the opioid crisis (which restricting supply can’t do on its own).

What we need is RESPONSIBLE prescribing and ethical pain medicine. Yes, sometimes that will mean withholding opioids. But it won’t mean abruptly cutting off patients or abandoning them.

/end