This month we look at a case involving an issue that is in the news daily – opioid prescribing. Opioids can provide substantial pain relief, but can also result in dependency, addiction, overdose, and even death, meaning that prescribers need to be judicious in deciding if opioids are the best option for their patients.
The patient, Mr K, 37, was a married father of a young daughter. He had been seeing his primary care physician, Dr W, for 7 years. In 2008, the patient, who worked in construction, slipped and fell injuring his lower back. A visit to the chiropractor didn’t resolve the pain, so Mr K went to Dr W that February complaining of significant pain. The physician ordered x-rays, a muscle relaxer, and ibuprofen as needed. The x-rays came back normal, but the patient called the next week complaining that the ibuprofen wasn’t working, and the pain was limiting his ability to do his work. He asked for a pain reliever. Dr W wrote a prescription for 30 hydrocodone pills, with one refill, to be taken as needed every 6 hours.
A month later, Mr K called Dr W and requested a refill, explaining that he needed to take double the number of pills to control the pain. The doctor refilled the prescription.
In April 2008, Mr K came to Dr W’s office complaining of continued back pain, and a worsening of pain by the end of the work day, which was helped by taking 2 to 3 hydrocodone pills. Dr W refilled the prescription and ordered an MRI. A few weeks later Mr K called to ask about the MRI results and again reported having to take more than the prescribed dose of hydrocodone for it to work. Dr W referred Mr K to an orthopedic surgeon who said the MRI did not show a need for surgery. Mr K also got a second opinion from another surgeon who said the same thing.
In July 2008, Mr K called Dr W and reported increasing the amount of hydrocodone and then trying to decrease it but that it caused him to “feel very bad, shaky, nose running, sweating, weak, yawning and moody.” When he took the medicine, he told the doctor, he felt better within an hour. “I think I need help,” Mr K told the physician.
The doctor had him come in the following month and noted that Mr K was doing better with the back pain and was taking hydrocodone 6 times a day with plans to wean back in a week. The physician noted that the plan was for Mr K to continue the hydrocodone but cut himself back on how often or how many pills he took. Dr W did not change the prescription.
In February 2009, when Dr W was on vacation, Mr K saw another physician in the same practice. This physician recommended switching from hydrocodone to extended-release oxycodone. He prescribed it to Mr K and told him to follow up with Dr W. A week later he saw his regular physician who noted that Mr K was still having pain but was tolerating the oxycodone extended-release tablets well with no adverse effects. The patient reported that the extended-release oxycodone was wearing off faster than he would like and had not eliminated the pain. Dr W continued to prescribe the hydrocodone in addition to the extended-release oxycodone.
This pattern continued, with the patient continuing to complain that the medication didn’t help as well as it used to. In August 2009, Dr W discussed possible adverse effects and risk of dependence, but both patient and clinician agreed that the benefits outweighed the risks. By October 2009, Dr W added an immediate-release oxycodone to the hydrocodone and extended-release oxycodone being prescribed. This went on through 2010 and 2011. By 2012, Mr K was having serious problems at home, with his job and with his relationship with his family. In May of that year, Mr K and his wife went to see Dr W to discuss weaning Mr K off opioids. Mr K told the physician that the pills were ruining his life. Dr W noted in the file that the patient was tolerating the medicine well and had no new adverse effects.
Over the next few months, the pharmacy called Dr W concerned about the large amount of opioids being prescribed to Mr K. At this point, Dr W began trying to taper down Mr. K’s immediate-release oxycodone. Eventually Mr K’s withdrawal symptoms became so bad that he had to be admitted to a rehab facility where he was diagnosed as having severe opioid use disorder.
Mr K recovered, but he and his wife divorced, and he lost his job as a result of the opioid use. He eventually sought the counsel of an attorney and sued Dr W and his practice.