Because of these difficulties in prescribing chronic opioids and, perhaps, because of a real concern about their societal impact, many primary care providers have become reluctant to continue their patients’ prescriptions. I suspect, without proof, that this reluctance is greater among mid-level practitioners who now provide a large part of primary care. They are turning to the specialist, including the rheumatologist, to take on this task.
What is your ethical obligation to the patient in the scenario presented? Based on a strict interpretation of responsibility, it seems the new primary care physician has taken on the medical management provided by the previous provider. It is then up to her to continue the hydrocodone, taper it or refer to a pain management specialist. When you accepted this patient into your practice, it was for treatment of his systemic inflammatory disease, not the chronic degenerative problems.
Based on what is best for the patient, you would take responsibility for the hydrocodone prescriptions. You probably have more experience and comfort in managing chronic back pain, although perhaps with no more success, than the family practitioner and have an ongoing, trusting relationship with the patient.
Based on the need to provide expert care to more patients with complex rheumatic diseases, you could choose to decline this task, which can be handled adequately by others. One option would be to contact the primary care provider. A conversation could resolve the situation, but you may be advised the practitioner or her organization has a policy against chronic narcotic prescriptions. In one similar situation, I was told an organization did not allow its physicians to prescribe narcotics; when I checked with this organization, I found the restriction was much less rigid than I was led to believe. Other organizations allow prescribing of opioids but insist their physicians follow the Centers for Disease Control and Prevention (CDC) suggestions for pain contracts and drug testing.
Recommendations
Present recommendations for chronic opioid use in nonmalignant pain include starting with the lowest effective dose of short-acting opioids. Dosing should be increased only gradually to reach pre-
established goals, and the patient should be followed regularly to assess whether the goals of treatment have been reached and whether the pain medication is providing enough benefit to justify the long-term risk, such as opioid abuse. The patient should also be screened for risk factors for opioid abuse. Guidelines recommend a pain contract and periodic urine drug screening.1,2
