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NPR's podcasts, Doctors Grapple With When To Prescribe Opioids For Pain

Doctors Grapple With When To Prescribe Opioids For Pain

RENEE MONTAGNE, HOST:

President Obama spoke out again this week about Americans' addiction to heroin and opioid painkillers. The abuse of prescription painkillers has reached epidemic levels, and among those blamed are doctors who prescribe them. In an essay in The Boston Globe magazine, one young doctor describes the challenges he faces when asked to prescribe opioid painkillers like OxyContin, Vicodin and Percocet knowing, he says, that they can lead to addiction. Dr. Sushrut Jangi is an internist at Beth Israel Deaconess Medical Center in Boston.

SUSHRUT JANGI: Whether or not a patient needs opioids is a very difficult question to answer. Frequently, we will see patients who we think might have been abusing opioids in the past with medical problems like kidney stones or a rash. And when they're in pain crying in front of you, it's very hard to not give them an opioid when you know that they're in such distress. MONTAGNE: Did do ever discover a patient who you originally prescribed opioids for pain who you discovered later became addicted?

JANGI: I'm not aware of cases like that. But I've certainly met many patients who I get the sense that they're dramatizing how much pain they have because they want opioids. I think it's a second sense that you start to develop that this patient is likely to abuse this drug. MONTAGNE: Well, what would give you that sense that a patient is sort of faking it?

JANGI: Most people who are in pain - they're not usually dramatic about it. They may actually even deny that they're in pain. Then we'll see a patient who comes in with more of a minor problem. The amount of pain that they display seems out of proportion to their injury. But since we have no clear method of assessing how much pain a person is in, we can't prove exactly what they're experiencing. MONTAGNE: Yes, it's interesting because it's self-reported on a scale of one to 10. JANGI: Yeah, so in the '90s, the Joint Commission that accredits hospitals came up with this scale which is the foundation of that question that doctors often ask. And since quality measures are linked to hospital reimbursement, hospitals became interested in ensuring that patients who are hospitalized had their pain adequately treated.

MONTAGNE: And is it also not true that doctors are trained to help patients, to keep them safe so these drugs would have seemed immediately like a wonderful tool?

JANGI: Right. I think we basically created this medical culture where seeing a patient in pain is unacceptable. In fact, a lot of people started considering pain the fifth vital sign. And there's really only one way to relieve pain quickly, and that's by using opioids. There's nothing else that does that. MONTAGNE: What is your threshold as a doctor for prescribing opioids?

JANGI: The way I think about opioids and the way I prescribe opioids has completely changed. And nowadays when I see a patient in pain in the hospital, we now know that even transient bursts of opioids that are given for a few days is enough to put a subset of patients at risk for developing chronic opioid abuse. So, you know, before I used to give morphine, Dilaudid at the drop of a dime. These days, I turn to NSAIDs like ibuprofen or Toradol, which often are as effective or sometimes more effective than opioids especially in the long run.

MONTAGNE: You talk about alternatives to opioid use including such things as meditation and physical therapy. But how hard is it to convince a patient who would maybe just rather pop a pill to switch and do the hard work that it takes to learn about these things and to do them and make their...

JANGI: Sure.

MONTAGNE: ...Appointments and what not?

JANGI: I think a lot of patients actually who are genuinely in pain - they're the ones that actually tell us I don't like pain medicine. I don't want to be on opioids. And oftentimes, we're the ones that say it's not risky. The morphine and the Percocet will help you through the first few days. A lot of patients are really looking for other solutions. That being said, yes, it's not easy. I think a lot of patients will struggle, and I think one of the messages that we need to put out there is having a little bit of pain is going to be necessary if we're going to curtail our use of opioids. MONTAGNE: So I think - to quote you - pain is a part of healing.

JANGI: Pain is a part of healing.

MONTAGNE: Dr. Sushrut Jangi is an internist at Beth Israel Deaconess Medical Center in Boston. Thank you very much for joining us.

JANGI: Thanks so much.


Doctors Grapple With When To Prescribe Opioids For Pain

RENEE MONTAGNE, HOST:

President Obama spoke out again this week about Americans' addiction to heroin and opioid painkillers. The abuse of prescription painkillers has reached epidemic levels, and among those blamed are doctors who prescribe them. In an essay in The Boston Globe magazine, one young doctor describes the challenges he faces when asked to prescribe opioid painkillers like OxyContin, Vicodin and Percocet knowing, he says, that they can lead to addiction. Dr. Sushrut Jangi is an internist at Beth Israel Deaconess Medical Center in Boston.

SUSHRUT JANGI: Whether or not a patient needs opioids is a very difficult question to answer. Frequently, we will see patients who we think might have been abusing opioids in the past with medical problems like kidney stones or a rash. And when they're in pain crying in front of you, it's very hard to not give them an opioid when you know that they're in such distress. MONTAGNE: Did do ever discover a patient who you originally prescribed opioids for pain who you discovered later became addicted?

JANGI: I'm not aware of cases like that. But I've certainly met many patients who I get the sense that they're dramatizing how much pain they have because they want opioids. I think it's a second sense that you start to develop that this patient is likely to abuse this drug. MONTAGNE: Well, what would give you that sense that a patient is sort of faking it?

JANGI: Most people who are in pain - they're not usually dramatic about it. They may actually even deny that they're in pain. Then we'll see a patient who comes in with more of a minor problem. The amount of pain that they display seems out of proportion to their injury. But since we have no clear method of assessing how much pain a person is in, we can't prove exactly what they're experiencing. MONTAGNE: Yes, it's interesting because it's self-reported on a scale of one to 10. JANGI: Yeah, so in the '90s, the Joint Commission that accredits hospitals came up with this scale which is the foundation of that question that doctors often ask. And since quality measures are linked to hospital reimbursement, hospitals became interested in ensuring that patients who are hospitalized had their pain adequately treated.

MONTAGNE: And is it also not true that doctors are trained to help patients, to keep them safe so these drugs would have seemed immediately like a wonderful tool?

JANGI: Right. I think we basically created this medical culture where seeing a patient in pain is unacceptable. In fact, a lot of people started considering pain the fifth vital sign. And there's really only one way to relieve pain quickly, and that's by using opioids. There's nothing else that does that. MONTAGNE: What is your threshold as a doctor for prescribing opioids?

JANGI: The way I think about opioids and the way I prescribe opioids has completely changed. And nowadays when I see a patient in pain in the hospital, we now know that even transient bursts of opioids that are given for a few days is enough to put a subset of patients at risk for developing chronic opioid abuse. So, you know, before I used to give morphine, Dilaudid at the drop of a dime. These days, I turn to NSAIDs like ibuprofen or Toradol, which often are as effective or sometimes more effective than opioids especially in the long run.

MONTAGNE: You talk about alternatives to opioid use including such things as meditation and physical therapy. But how hard is it to convince a patient who would maybe just rather pop a pill to switch and do the hard work that it takes to learn about these things and to do them and make their...

JANGI: Sure.

MONTAGNE: ...Appointments and what not?

JANGI: I think a lot of patients actually who are genuinely in pain - they're the ones that actually tell us I don't like pain medicine. I don't want to be on opioids. And oftentimes, we're the ones that say it's not risky. The morphine and the Percocet will help you through the first few days. A lot of patients are really looking for other solutions. That being said, yes, it's not easy. I think a lot of patients will struggle, and I think one of the messages that we need to put out there is having a little bit of pain is going to be necessary if we're going to curtail our use of opioids. MONTAGNE: So I think - to quote you - pain is a part of healing.

JANGI: Pain is a part of healing.

MONTAGNE: Dr. Sushrut Jangi is an internist at Beth Israel Deaconess Medical Center in Boston. Thank you very much for joining us.

JANGI: Thanks so much.