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The Pit and the Pendulum of Narcotic Prescribing


By Gus Geraci, MD

I’ve got enough grey hair now that I’ve seen some patterns in how things seem to work over time. Estrogens for menopausal symptoms came and went, mammograms, pap smears, PSAs, and enough other strenuous recommendations came out strongly, faded and resurged, sometimes to fade again.

All of these changing recommendations remind me of the Edgar Allen Poe story of the Pit and the Pendulum. The unnamed character, sentenced to death, finds himself in a cell in complete blackness, and attempts to find his way. He is apparently drugged, then finds himself tied to a table with a pendulum slowly being lowered where it will mortally wound him.

We who practice medicine are laying there with not only a slowly lowering pendulum, but it also moves ever so slowly from side to side, in the form of recommendations that change and swing, all based upon or supported by the solid scientific and sometimes social reasoning of the day. If you fail to follow the recommendation, it will mortally wound you.

Thus it is with narcotic prescribing.

A few years ago, pain relief using our judgment was not enough. The public outcry was that we were not treating pain well enough. We were given guidelines, pain was a vital sign, and comfort was key. The presence of pain, however minor, was a bad thing.

That diagnosis remains supported by surveys used in hospitals today.

Our job was to eradicate pain, and narcotics were the key when lesser medications did not work. The potential abuse of narcotics was tempered by opiate agreements, questions and surveys, but largely overridden by the need to relieve pain as our primary directive. Unwittingly, we created addicts out of more than the absolute minimum number of people who “really” needed narcotics.

The swing back came shortly after. The rising surge of narcotic use, addiction, and abuse wrought a demand for “sensible prescribing.”

Physicians who were a bit too eager to eliminate pain as directed and requested by the guidelines and the documentation of unhappy faces started being prosecuted for lack of medical necessity and “proof” that the patient was in pain.

The proof of a 10/10 unhappy face was not sufficient, there had to be some evidence that the pain was real, and we were to now minimize the use of narcotics. They were only to be used as a last resort when all other -some very expensive and unaffordable- interventions had failed.

Pain relief as a specialty arose, and some of us reacted a bit too harshly, and started prescribing so cautiously the patients began to complain that they were getting no relief and being treated as abusers when their previous stable regimen of taking three narcotic pills a day had worked for them and kept them productive for years.

Now being asked to attend rehab, physical therapy, and subjected to interventions that they could not afford nor had time to do, the supply of narcotics became scarce. Some turned to street drugs, clearly a bad solution, but for some the only resort to allow them to keep working, until they got caught, got ill from bad dosing, or died.

The Pennsylvania Medical Society, along with the state and other stakeholder groups, have worked diligently for the last year or so crafting new voluntary guidelines here in Pennsylvania. Guidelines now exist for the treatment of chronic, non-cancer pain, treatment of pain in the emergency department, and treatment of pain in dental practices, and others are in the works.

They can be downloaded on PAMED’s website at www.pamedsoc.org/opioidguidelines. There is also a CME course – “Addressing Pennsylvania’s Opioid Crisis: What Health Care Teams Need to Know” – that takes a deeper dive into the guidelines.

There are numerous devilish details to guide us, and best practices are outlined, limits are described, and hopefully the pendulum will swing back to a happier place.

Our efforts included many — dental, emergency, primary care, oncology associates, and other providers and stakeholder groups, in addition to the state. We have all collaborated to bring forth the latest guidelines, which hopefully will minimize unnecessary prescribing, but provide pain relief to those that respond only to narcotics.

A few more years, and we’ll see which way the pendulum swings.

Note: This column was reprinted with permission from the Pennsylvania Physician Magazine.

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