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Today I have a sick headache from chronic pain. Not MY chronic pain, but from trying to treat chronic pain as a family practice physician.

I am tired of being yelled at this week. In all sorts of forums. The new pain medicine law in Washington State sets prescribing limits on pain medicines for primary care doctors, in response to the accumulated information that opioid pain medicines are less safe than previously supposed. The death rate from prescription medicines correctly taken has passed deaths from motor vehicles for the entire US. This is a bit worrisome to physicians who take an oath to "first, do no harm". However, the local Employed Doctors, who work for the Corporate County Hospital District, haven't figured out the law yet. I keep getting patients who are on chronic pain meds above the primary care doc limit who have to either taper or get blessed by a pain specialist to stay on higher doses. They are furious and threatened. I try to patiently explain that while I do want to update their pain treatment, I both have to follow the law and I don't want to kill them. I know which doctor drafted the Corporate County Hospital chronic pain policy, more than 100 pages worth. That was based on the 2010 pain medicine guidelines. I talked to her yesterday and she doesn't know the dose ceilings in the new law, which has gone into effect for DOs, but hits MDs on January first. And two patients have named other doctors in the system who haven't brought the dose ceiling up at all.

The ceiling for daily methadone is 20mg a day, which is 80 morphine dose equivalents. The law says up to 120 morphine dose equivalents, but methadone is a weird long acting drug, so 21 mg is 165 morphine dose equivalents. The doctor who helped draft the hospital clinics' pain policy asked me what the methadone ceiling was yesterday. My internal response was oh, shit, as I said, "20 mg daily." Silence for a moment, then, "Oh, dear. We have a lot of patients on more than that." She is going to a conference next month. It makes me tired just thinking about all hell breaking loose again locally, as the doctors struggle to learn it and explain to the patients. I took a class in treating opioid dependence with buprenorphine in November 2010, and have been working with the University of Washington Pain and Addiction Clinic since then, and I am still struggling to understand and articulate the current understanding of pain treatment. They seem to be coming around to what I've thought for a long time: opiates are better for acute pain than chronic pain, they have limited utility for chronic pain, they addict people (more that previously thought). In addition, opiates can cause hyperalgesia, making pain worse, and combinations of medicines or medicines with alcohol have a high overdose death rate even if taken as directed. I talked to our pharmacist who has been here for 28 years. He says the pendulum is swinging, from treat chronic pain with high dose narcotics, to something else, and he's seen it go back and forth in his career.

I'm at the point in understanding now where most of my questions seem to be the cutting edge questions. The replies are "We don't know." or disagreement among the panel: a pain specialist, a psychiatrist, an addiction specialist and then often one or two other panel members. I am having trouble defining exactly what opioid dependence is, and the psychiatrists and the addiction doctors are fighting that out at the national level. The psychiatrists have the DSM-IV diagnosis but the addiction docs say it's a chemical brain disorder, not a psychiatric disorder at all. Lots of controversy.

I just want to do what I can for patients, for people in my family practice clinic. My head hurts less writing about it. And it's okay to stay in bed today, with a sick headache. I think staying in bed is a reasonable way to deal with it, especially since right now I'm not too interested in taking pain medicine.

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