The other day I was asked how I felt about pain management. It was at the end of a lunch with a potential employer. We were half out of our seats, about to return to the clinic where this primary care doctor had patients waiting. I’d already talked her ear off about everything from the need of PCP’s to focus more on diet and exercise to the need to focus more on end of life planning. And now she asked me about pain management.

As I paused to take a long, anticipatory breath, she explained the need for pain management was very great where we lived. She said this with a knowing look and half-chuckle that could have been interpreted different ways. It might have meant: you know how important and overwhelming the need is because we really should do a better job keeping people pain free. I choose it to mean: isn’t it a ridiculous situation we’ve gotten ourselves into with so many people addicted to prescription opioids. So I opened my mouth.

At the end of our short walk back to her office I realized my interpretation was wrong. And the likelihood of her hiring me was nonexistent. My stance of refusing to give opioids to people with musculo-skeletal pain did not go over well. During my descriptions of difficult pain medicine addicted patients I’d seen in the hospital, who were abusive when I stopped their opioids, her previously agreeable attitude turned uncertain and nervous. She asked what I said to a patient who told me I was being mean. I repeated what I say to all my patients-deaths from prescription opioid overdose are at an all-time high and prescription opioid dependence is linked with current heroin epidemic. That and the fact opioids have not been shown to help in chronic musculo-skeletal pain. The primary care doctor nodded as I talked but the way she squirmed belied agreement. As did her half-hearted handshake when I finally shut-up.

This is an excellent primary care doctor, probably the best in my region. Her praises are sung by patients and doctors alike. Even from our short meeting it was obvious how deeply dedicated she is to providing the best possible primary care. But taking a hard-line stance on the use of opioid pain medication is not in her agenda.

Unfortunately this is not surprising. More surprising is how only now people are finally realizing the truth behind prescription opioid prescribing. It’s not just a handful of prescription mills causing the massive epidemic we’re facing. It’s the everyday primary care doctor that’s just as responsible. And the reason is simple. They care, they want their patients to be happy. They don’t want their patients to be mad or dissatisfied. Just like enabling family members of drug and alcohol abusers they have a hard time saying no to people they care about who are in significant distress. This is especially hard in our current environment where subjective pain is evaluated on a self-reported numerical scale as if it was an objective vital sign such as blood pressure or temperature.

Another not well discussed part of the problem is the ER. The objective of the ER doctor is to move the patient safely and quickly out of the ER, either as an admission to the hospital or as a discharge home. When confronted with a patient complaining of musculo-skeletal pain the quickest way to get them out of the ER is to give large doses of IV opioids and a prescription for pills. In large communities with multiple hospitals pain medicine addicted patients regularly rotate their ER visits, as well as their pharmacies, so the actual amount of opioids they are legitimately receiving is almost impossible to tract. In small communities with just one local hospital these patients are easier to monitor, but in my experience the ER continues to take the path of least resistance-excessively dosing and over prescribing opioids.

Knowing what is happening in the medical community is one thing. What can we do about it? I believe the first step is stop prescribing opioids for musculo-skeletal pain. This includes weaker opioids such as Percocet or Vicoden. A combination of NSAIDs and tylenol with appropriate physical therapy modalities is the best course to take for musculo-skeletal pain. Second step is to better manage the patients who are pain medicine dependent. Instead of feeding their addiction physicians should work with them to slowly come off opioids using inpatient or outpatient drug rehab as needed. Third step is to break the ER cycle of blitzkreig treating. Have good tracking systems to identify pain medicine abusers and social services in place to immediately refer them to rehabilitation facilities.

Patients will be pissed. They will scream, curse, plead, bargain, demand, threaten. They will call doctors every name in the book and transform into frightening, rage-filled monsters. Every family that’s ever dealt with drug and alcohol addiction has seen it. The simplest thing to do would be to give them what they want. But we need to be better than that. We need to give them what they need-help to overcome their opioid dependence.