Why Are Doctors Reluctant To Prescribe Adequate Pain Medication?

I have re-occurring kidney stones from time to time. They disappear for one to two years, then come back with a vengeance for two weeks. I seem to be getting Tylenol-intolerant, but doctors are not anxious to write prescriptions for other drugs such as oxycodone which doesn’t cause nausea like Tylenol does.

The pain can be managed with these until the stones are passed, but without the medication, I just want to die. The doctors say these are schedule II drugs, whatever that means. When I try to convince the doctors that these work, they look at you like you are a junkie. Any help or suggestions?

The pain of kidney stones can be very severe. Many women who have had children and passed kidney stones describe the pain from the stones as worse than labor pains. Unfortunately there is little to be done during the acute period when a stone is passing except to give pain medication, and push fluids to increase urine production and thus push the stone out faster. Small stones will eventually pass, and it sounds as though this has been the your experience, but it is unethical, in my opinion, to deny a person adequate pain relief during the painful period that the stone is passing.

Nonetheless, the problem of obtaining adequate pain relief is quite widespread, even for people with terminal cancer who have a verifiable cause of pain, have a limited life expectancy, and can have their final days turned into days of torture for lack of adequate pain control. This question has been much in the news in the past few years, but despite publicity regarding the problem, surveys of care for the terminally ill repeatedly show that 30 to 50 percent are receiving inadequate pain control.

Why is this? Why are doctors not more aware of their patients’ pain, and more willing to do whatever is necessary to relieve it? There are probably a number of reasons, which will vary from doctor to doctor, and between different patients in a doctor’s practice. Often doctors will not be aware of the intensity of pain being described by their patient, may think that the person is exaggerating, or may actually suspect the person of making up a pain in order to obtain narcotics. Even if doctors fully understand how severe the pain is, they may be unwilling to prescribe narcotic-type drugs for fear of producing addiction in their patients.

Many studies have shown that narcotics prescribed appropriately for pain relief are very unlikely to result in addiction (Harrison’s Principles of Internal Medicine, 14th Edition, p. 57). However, every doctor has heard stories about people addicted through medical prescriptions, and stories about addicts complaining of pain in order to obtain drugs, and so this fear is perpetuated.

Doctors are also worried about legal action against them if they are believed to be prescribing narcotics or other controlled substances too easily. Action can be taken by the Drug Enforcement Administration (DEA) to remove a doctor’s right to prescribe controlled substances, and also by state professional review organizations which can suspend or revoke a doctor’s license to practice. The DEA, responsible for the federal war on drugs, has often talked aggressively about going after doctors who prescribe too freely, in the opinion of the agency; and has recently been threatening doctors with sanctions in states that have approved the medical use of marijuana, even when they are prescribing in accordance with the laws of the state in which they practice.

Doctors also often express concern that, if they prescribe large doses of narcotics to terminally ill patients, they will be accused of assisted suicide or hastening the person’s death.

Because you do not have a fatal condition, you probably have much more difficulty getting adequate pain relief than a terminally ill cancer patient. I can suggest a number of things that you might do to make it easier for you to get such relief in the future. First, you should have a regular doctor, and make a point of acquainting your doctor with your past medical history, including sonograms or x-rays of the stones that you have had, emergency room records of prior episodes of stones, or records from your earlier doctors. This will hopefully convince your doctor that you don’t have a serious problem, and that it is likely to recur in the future.

Secondly, you should be knowledgeable about pain medications, and willing to work with your doctor to find the best dose and best medication to control your pain. Many people develop nausea when they take Tylenol with codeine, which is what I believe you are referring to when you use the word Tylenol. On the other hand, oxycodone, (Percodan and others), is a strong narcotic, in category II which is the same category that morphine and Demerol are in.

There are intermediate drugs such as hydrocodone (Vicodin and others), which are often combined with acetaminophen (Tylenol) or ibuprofen (Motrin) and therefore attack the pain from several directions at once. Hydrocodone is a CIII drug, and is much less rigidly controlled than the CII drugs. Acetaminophen, non-steroidal pain medications such as ibuprofen, and the narcotic pain medications all work in different ways, and can be combined for their additive effect. Displaying too much knowledge about narcotic drugs can backfire, however, since some doctors will assume that this implies frequent drug-seeking behavior; so I would suggest that you develop a relationship with your doctor before coming out and saying that you need Vicodin or Percodan.

Doctors, like everyone else, hate to feel that they are being conned. But, developing a relationship based on your medical condition, past records, evidence of stones in the past, and not skipping around to other doctors or emergency rooms trying to obtain narcotics will, I hope, facilitate your ability to get adequate control for this painful condition.

 

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