Day 42: Beliefs

It is interesting how narrow minded we can sometimes become when we are completely entrenched in our one field of medicine.  For example, the physician who runs the addiction medicine program in psychiatry believes that all people with pain should be on buprenorphine, an opioid that is used in people with substance use disorder.  It seemed to me that she felt that no matter the reason for someone's pain or need for pain medication, regardless of the amount of medication they may need for their pain, they should be on a medication that has a very low threshold for its maximum therapeutic dose.  While I am a huge proponent of being thoughtful in regards to helping work with patients on best treatment options, even if they aren't opioids, I think like anything, we cannot make broad, sweeping statements about treatment options.  Just like with any disease, there are certain medications that are used in certain situations.  We are taught that there is a hierarchy, even in cancer pain which is the one area that opioids are approved for use.  Even there, we start with more benign medications before escalating.  We recommend non-pharmacologic interventions to be done along with medications.  There is a great deal of counseling before starting someone on opioids.  It is not a decision taken lightly.  In the same vein, there is no one medication that is right for everyone.  There is as much harm done in under-treating as in over-treating.  There is a reason why interventional pain and palliative medicine fellowships exist, and it is to have people who are more thoughtfully trained in discerning the best pain management approach and working as a team, especially with people who are at risk for developing or have a history of substance abuse disorder.  I am not going to put my foot down and say I will only prescribe one medication and leave myself in a place where someone is suffering because of my rash decision.  That is not the purpose of the extra training.