Navigating the Labyrinth of Prescribing Practices for New Residents

lauren_wood_wht By Lauren Willis Wood, MD

As first year family medicine residents, our patient care experiences really run the gamut, since our training truly encompasses “cradle to grave” care.  With the exception of most pediatric care, the issue of narcotic prescribing and addiction is seen in all specialties, as well as frequently in continuity clinic where we care for our own primary care patients.  As dangerous as opiate medications can be, they can also be very useful for short-term pain management.  This dichotomy can make navigating the labyrinth of prescribing practices quite perplexing, especially for new residents.  Developing a personal prescribing “rule-book” is wrought with contradictory input based on experiences with different specialties and attendings.  While often not the initial prescribers, primary care providers can become responsible for long-term medication management decisions for our patients.

These are not always simple decisions, but can have great impact on our patients and the greater population.  Statistics quote millions of narcotic abusers in the United States with a staggering rate of increase over the past 20 years.  It is easy to wonder why these medications are prescribed at all.  According to the CDC, poisoning is now the leading cause of accidental death in the US, with opioids being the culprit in over 70% of pharmaceutical related overdoses. While some patients do illegally obtain narcotics, most abusers were initially prescribed these medications by a physician for a legitimate complaint.  There can be huge variability in individual susceptibility to dependence, medical comorbidities and unique psychosocial factors that impact a patient’s response to treatment with narcotics.  Amongst all of these scary statistics, diverse opinions and unknowns, how are residents supposed to develop prescribing practices that are best for patients, providers and the medicolegal landscape at large?

Perhaps I find this particularly perplexing because of some of my experiences through medical school.  Before medical school, I worked at a small family practice with three physicians.  A major part of the practice consisted of patients with substance use disorders – particularly patients being treated with Suboxone for narcotic addiction.  For some of these patients, this medication had allowed them to reformulate lives that had been shattered by addiction, most often started by seemingly appropriately prescribed pain medications.  In medical school, I realized that this was not a topic that was adequately addressed, if at all.  Learning about over-prescribing of pain medication most commonly consisted of brief conversations with preceptors, at random and dictated often by chance or student interest.  I pursued further elective time in addiction medicine with a Family Medicine trained doctor whose entire practice was addiction treatment – again, primarily narcotic addiction.  Seeing patients actively withdrawing and hearing stories of ruined lives scared me off of these medications, although there are times when I think they are a good option for patients.

Residency has not offered much more clarity on this issue.  Even within specialties, some providers have a strict no-narcotic stance while others seem to have more liberal prescribing practices. There really is no consensus on the topic.  Maybe the elusive “rule-book” I was hoping to find doesn’t really exist.  In reality, most things in medicine are not absolutes.

Upon returning to our continuity clinics from far-flung rotations, we have the opportunity as primary care providers to build relationships with our own patients and address the issue of opioid overuse.  Instead of writing off patients on chronic pain medications, my hope is to stick it out with them and explore alternative options for pain management or therapy. Sure, there are likely patients who simply want any provider who will offer narcotics and certainly many chronic pain patients are not interested in stopping their pain medications.  However, the success of helping even one patient get off of narcotics or preventing addiction in one patient by avoiding prescribing is a small, but significant, victory.

Lauren Willis Wood, MD is a first year Family Medicine Resident with the University of Utah School of Medicine

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