It's the patient's responsibility to find a doctor who knows how to screen for addiction.

It's the patient's responsibility to find a doctor who knows how to screen for addiction.(ISTOCKPHOTO)

The chance of becoming addicted to narcotic painkillers is around 1 in 500 when patients are properly screened before their doctors hand over a prescription, according to a 2008 meta-analysis that examined 2,500 chronic pain patients. With less careful screening, the risk can rise to 1 in 30.

The tricky part for pain patients, says David Fishbain, MD, a professor of psychiatry at the University of Miami, is finding a doctor who knows how to do the screening.
When Your Doctor Won't Prescribe Narcotics


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The patient's responsibility
Pain patients are often bounced from family doctors to specialists and back, with no one taking the time to monitor their ongoing use of the medication, or to “qualify” them for what the medical profession calls chronic opioid analgesic therapy (COAT)—the taking of narcotic painkillers for a long period of time.

That means it falls to patients to find health-care practitioners who are experienced in working with chronic pain patients, so that the physicians are comfortable deciding both when to prescribe narcotics and how their use can be safely monitored.

The top warning signs of addiction risk are, not surprisingly, a history of illicit drug use or alcohol abuse in the patient or his family. But smoking is also on Dr. Fishbains radar, because “any addiction is a potential risk factor for another addiction.” And there's a long list of factors that may be less predictive but still relevant, including depression and anxiety disorders, which means that doctors need to consider the patient's entire history and not just how he or she answers a few targeted questions.

[ pagebreak ]More work for the doctor
Once a patient is on COAT, physicians have to watch for behavior that may presage or signal addiction, which includes the use of multiple doctors and pharmacies for prescriptions, as well as calling in early for refills. Doctors often ask patients to sign narcotics contracts; they also may issue only short-term prescriptions, and some docs even require urine tests.

So having a patient on narcotics is a lot of work for a careful doctor, and that, Dr. Fishbain says, explains why family doctors, also known as general practitioners (GPs), can feel caught in the middle.

“GPs are in the unfortunate position of having patients who have been put on COAT by specialists," he says. "But the specialists dont have the time to [screen and monitor]; they want to do more invasive procedures [such as back surgery], so they send the patients back to the GPs. The GPs then have the patients but dont know what to do.”

This all adds up to a lot of narcotic prescriptions being prescribed by poorly informed doctors, says Dr. Fishbain.

How to find the right care
“You should try to find a physician who has experience in pain management and who has experience in chronic opioid analgesic therapy," recommends Dr. Fishbain. "They need to be up on the literature and aware of the screening.”

In other words, the educated patient has to do his own screening to find the educated doctor. Referrals—to a pain clinic, for example—are reassuring, but theres no substitute for asking questions up front and starting out with a GP who knows how to prescribe for chronic pain.