Ellen Boulder filed a complaint against Dr. Kim and it was my job to handle it.
Her previous physician had retired and she had been reassigned to see Dr. Kim, who was trying very hard to limit his opioid prescribing.
Ms. Boulder had been on moderate doses of hydrocodone for years for osteoarthritis, lumbar disc disease and chronic sciatica after a failed back surgery. She had also been diagnosed with fibromyalgia.
Dr. Kim explained to her, and documented everything impeccably thoroughly in the medical record, that long term opioids have been shown to be less effective and carry greater risk for debility and death than non-opioid pain medications. He also explained that hydrocodone can cause a fibromyalgia-like condition called opioid induced hyperalgesia, which can be more debilitating than the condition the opioids were prescribed for in the first place.
He outlined a slow tapering schedule that he printed out for her and he prescribed a starting dose of gabapentin. A few days later, she had called and reported severe drowsiness, generalized swelling and tingling all over from the gabapentin. She refused to take any more of it, but wouldn’t come in to document her swelling and talk about what to do next because her car was in the shop. Dr. Kim prescribed 10 mg of amitriptyline at bedtime until her next appointment and didn’t hear from her until one week before her hydrocodone, at the lower dose, would have been due for a refill.
When she called and left a message that she needed a refill, Dr. Kim sent the message back to his medical assistant with the reply “not due until next week”.
That’s when the barrage of noisy phone calls started, back to the medical assistant, to the on-call doctor that evening, to our nursing supervisor and care coordinator the next morning and to our Chief Operating Officer just after lunch.
By 4:30 it was my turn. My COO sent me an urgent message to review the situation and deal with the patient’s concern. Ms. Boulder wanted to fire Dr. Kim and get a different provider.
On the phone with me, she spoke softly. She described how she had struggled to remain functional with her chronic pain and never mismanaged her hydrocodone. Then she proceeded to tell me that her brother had been taken off his pain medications a few years before and had turned to heroin. Maybe she had no other choice herself if she couldn’t stay on the hydrocodone. And Dr. Kim had given her no warning that she was supposed to come off it this quickly.
I told her I had read the detailed instructions Dr. Kim had printed out for her about how to reduce her hydrocodone.
“But I had to take more than he wanted me to because of my pain being out of control, I went from a “5” to a “10” with just two pills less per day.”
I answered: “Well, you’ve been through our pain program, you know that our pain experience is influenced by our frame of mind, you’ve been upset about the taper and may have expected to hurt more….”
“My pain is real”, she interrupted. “And if I can’t have my hydros, I may have to turn to heroin, just like my brother. He got into trouble when he was on heroin, lost his job and his family. Then he went to rehab and was clean for a year but his pain was unbearable. Then they prescribed amitriptyline for him, just like Dr. Kim did for me, but I won’t take it, because – you know what happened? He killed himself with it, it’s more dangerous than a few measly hydros every day ever was. I refuse to take that kind of medicine.”
I answered: “I know Dr. Kim is more than willing to work with you at finding other ways to manage your pain.”
“But you’re the Medical Director, you can tell him not to cut me down.”
“No, I can’t, and you know that this is something every doctor is doing now as we see what the long term risks and consequences of opioids are.”
“But Dr. Kim doesn’t listen to me. You do, would you see me instead? I’m afraid of the kinds of medicines he wanted to give me, and I don’t want to end up on heroin, like Johnny.”
“All the doctors here have agreed not to go against a colleague’s tapering of opioids, because that is the road all doctors are on now, there are only some small differences in how fast we are going.”
“So are you saying I have to become a heroin addict?”
“No, I’m saying…”
“None of you doctors is taking responsibility for my pain, and it is your job to do that”, she interrupted.
“Actually, our first responsibility is to do no harm”, I answered. “Pain relief that is risky or dangerous doesn’t always help, it can hurt and we know that now.”
There was a long pause.
“I’ll just have to find another doctor”, she finally said.
“I’m afraid you’ll hear the same words everywhere you go these days”, I answered. “Times have changed.”
After another pause, she said “thank you for at least calling me back”, and hung up.
A Country Doctor Writes: 
yes, times have changed. We have allowed the collective hysteria over “the opioid crisis” to negatively influence how we treat post-operative pain here in Maine. The regulators have put in place so many hurdles that prescribing legitimate opioid post-operative pain medication is difficult and at times almost impossible. The e-scribing mandates must have sounded wonderful to the politicians and computer geeks who initiated them but the system rarely works and forces me to then write hand written prescriptions which in turn forces the patient to return to the hospital pick up the script (since I can’t call it in or FAX it to the pharmacy). As doctors, we have farmed out too much of our practices to those who have no patient contact, no clinical background. Why I have to contact the IT department 4 or 5 times a day to resolve computer issues frustrates me to no end.
This is such a difficult situation for everyone. I know that chronic pain is often very debilitating emotionally, and that fear of pain increases perceived pain. I have also seen at close hand how some patients abuse opioids, often for many years.
If this lady decides that heroin is her only livable option, then that’s what she will pursue. I hope she thinks again and gives her physicians a chance to help her. It does sound as if addiction and mental health issues are part of her family background, which complicates the picture quite a bit. I would recommend some individual counseling for her in addition to her medication management, to support her change in treatment if nothing else.