“I try to avoid using any opioids in a new fibromyalgia patient. Unfortunately, a whole cadre of patients with [fibromyalgia] who are already on opioids, come into my practice,” he says. “I insist they see pain management for those treatments, because they’re very, very difficult to manage, and it is a challenge trying to get [patients] off opioids at that stage.”
A Pain Agreement
When a patient takes opioids for an extended period of time, Dr. Greer uses a patient pain agreement—he’s careful to never call it a contract. The agreement “lists and defines what the expectations [of opioid use] are.” The agreement states only one doctor prescribes opioids for the patient and the patient must come to regular office visits. They must submit to pill counts and random drug screenings and agree not to sell or otherwise divert the medication.
In 30 years of using the agreement, Dr. Greer says patients have refused to sign this agreement on only two occasions.
“I tell them, ‘the agreement is there to protect you, the patient, [to ensure] you’re taking [opioids] appropriately. And if anyone questions your use of opioids, you have this agreement, signed, that says you’re going to take it the way you should be,’” he says. “It’s really to protect you, as well as the physician, to make sure we’re doing things for the right reasons.”
Dr. Weselman says deciding what alternatives to use—when alternatives are applicable—is a process that takes diligence. Both she and Dr. Greer note that sometimes consulting with a pain-management specialist is helpful.
“It requires really understanding what the underlying process is, what the diagnosis is, what’s driving the pain,” she says. “It’s getting to know the patient and understanding whether they have coexistent anxiety, insomnia, depression—what’s going on in their life. Because all of that affects patients’ pain levels and their ability to cope with it. All of that takes a lot of time.”
Richard Quinn is a freelance writer in New Jersey.
