The Ethical Dilemma: Disciplining Patients Misusing Pain Medication

As a pain management doctor, the relationship with a patient is more akin to a partnership in managing chronic pain rather than a strictly hierarchical employer-employee dynamic. However, the question arises: what should a pain management doctor do when a patient stops following prescribed guidelines and begins misusing their pain medications?

When Doctors Encounter Misuse

"I am disgusted but not surprised that you received the answers you have so far," says a seasoned pain management doctor. Doctors are expected to handle such situations with clinical judgment, empathy, and a deep understanding of the complexities involved. Physicians must weigh the potential consequences of ending the physician-patient relationship against the patient's well-being.

"I would not employ a doctor who answered this without clarification. You see, they cannot 'fire' the people that they work for. I pay my doctor; he works for me. I would fire my doctor if he answered this question unless he stated that the term used is not 'fire' but 'ending the physician-patient relationship.'"

Substance Use Disorder and Patient Rehabilitation

According to this doctor, ending a relationship for opioid misuse is not an option for two primary reasons:

Patients with substance use disorder need help, not dismissal. Disciplining a patient for misuse could drive them to seek care from another doctor, who might continue to prescribe the same medication recklessly.

Instead, the doctor focuses on offering alternative treatments and rehabilitation programs. For example, they might provide:

Non-opioid, non-narcotic medications. Non-medication treatments such as physical therapy, acupuncture, and psychotherapy. Injection therapies suitable for the patient's condition.

A Case Study: The Fentanyl Eater

One particularly stark example the doctor shares involves a patient with long-term opiate therapy. This patient was using a high-dose fentanyl patch (125 to 175 micrograms per hour) and admitted to eating the patches to obtain a rush of pain relief.

"He came into the clinic and admitted he’d eaten the fentanyl out of his patches - which are supposed to last three days. Each. I was amazed that he was alive let alone conscious and mobile."

The doctor emphasizes, "You know we have to fire you from the clinic." The patient's response shows a stark understanding of the situation: "Yeah I know..." The doctor then asks, "But I gotta ask you: How did you feel?" The patient replies, "Amazing! I was pain free for 12 hours."

Before the patient could get any higher dose or find a new doctor, the clinic took swift action. The patient was promptly dismissed. The doctor notes that the term 'fire,' when used in medicine, is almost exclusively in relation to patients' opiate use.

Conclusion

The ethical dilemma faced by pain management doctors when confronted with patients misusing their pain medications highlights the delicate balance between patient welfare and ethical responsibility. Doctors' choices in such scenarios can have profound and lasting impacts on their patients' lives. The empathy and clinical judgment shown by the doctor in this case provide a beacon of hope for those struggling with substance misuse.