How do I avoid a fight between my doctors?

February 25, 2009 8:19 AM

How do I handle my doctors' disagreement about what medication I should be taking?

I recently started seeing a psychiatrist to help with my long-standing depression and anxiety. As I also have chronic pain, he's suggested that I go back on regular doses of a "heavier" painkiller such as hydrocodone.

My regular doc currently has me on tramadol and lyrica for pain control; they help a lot but I'm still in pain every day and it interferes with work, sleep, life. I had also been on hydrocodone, taken on an as-needed basis, but he took me off that as he said "there's nowhere to go but up" with the opiates. The shrink's position is that smaller regular doses of pain meds can be maintained without ruining tolerance, and would have a salutary effect on my mental state.

I like both my doctor and my shrink, and would like to not be in pain, and don't want to get in the middle of a weird doctor fight. What's the best way to deal with this sort of situation?

posted by anonymous to health & fitness (9 comments total)

Go get another opinion, get him all the info from both doctors, let him make a decision of which doctor has a better opinion, and stay with the doctor he chooses.
posted by hal_c_on at 8:27 AM on February 25

generally I would trust the physician with the pain side and the psychiatrist with the emotional side of dealing with pain. Emperically (and not knowing much about your case) I would say that Lyrica addresses the mechanism of chronic (neurogenic) pain while hydrocodon is purely symptomatic. Lyrica has lower risk of tolerance.

Again, I am not giving you medical opinion, but some antidepressants enhance the action of Lyrica. Have you considered a combination?

I think your two treating physicians should work as a team to get the best result for you and not to advance their opinions. You be the judge to decide what works best for you and one way to go may be to get second(third) opinion
posted by london302 at 8:32 AM on February 25

I'd actually bounce it off your pharmacist at your next refill. Not the order taker, but the one that's there to make sure they don't screw-up and knows the drugs and how they interact and what they should be used for. Surprisingly they seem to often know more than the doctors about what you should be taking. But then, I'm used to walk-in doctors who don't know your history and want you out of there ASAP.
posted by hungrysquirrels at 8:42 AM on February 25 [3 favorites]

Taking Vicodin or Lortab long-term will have adverse effects on your liver. Narcotics are not a treatment for pain, narcotics are merely pain control. Lyrica is treatment for pain. Spinal cord stimulators are treatment for pain. You have options besides hydrocodone.

I second hungrysquirrels suggestion, speak to your pharmacist, especially about the long-term effects of your medication.
posted by realchild at 8:53 AM on February 25

For your sake, the first thing I'd recommend is for doctors should be in contact with each other and not communicating with you as an intermediary. This often leads to misunderstandings and miscommunications, and either doctor may be privy to information lacking to the other. So I'd suggest that you tell them to discuss the issue directly.

Personally as a practicing physician, let me tell you that there is plenty of wisdom in what your regular doc is saying. The use of stronger opioids for the treatment chronic pain is a road to be avoided unless no other alternatives exist, and the combination you're currently on suggests that your doc actually probably does know a thing or two about chronic pain management. That said, on a case by case basis rules of thumb do often need breaking, and if you still are having pain interfering with daily life you need to make that clear to him or her. This is particularly true if your incapacitating pain is truly episodic and would only require very occasional use of stronger drugs. Perhaps there's something else out there for you or perhaps you might benefit from seeing a pain specialist.
posted by drpynchon at 9:27 AM on February 25 [1 favorite]

I'm with drpynchon on the "get a pain specialist's third opinion" and bring the other two docs into the discussion. Each doc seems to have some good arguments for his/her position. A pain specialist is going to have even more information about the risks and benefits of the various drugs than will either a primary care physician or a psychiatrist.
posted by Sidhedevil at 9:34 AM on February 25

The biggest demographic for opiate usage is in the treatment of chronic non-malignant pain. If your docs answer was as you said, and otherwise not based in a tangible assessment of some increased risk on your part of abuse, then they are reflecting a lack of training and current paradigmatic understanding of pain management. Opioids are a tool, and in the right cases are rarely abused. You either need a primary doc with a more rational approach to pain that is not rooted in fear for their livelihood in the face of a rational clinical need, or a pain specialist, but eventually the primary will be asked to take over prescribing, at which point you may find yourself in a similar situation. Opioids are not especially helpful for certain types of pain, but that's for you and a specialist to discuss.

Please don't ask your pharmacist. You'll get an answer that has no basis in real-world pain management.

Opiates do not cause liver damage. Acetaminophen, often in certain opiate blends like Vicodin, can, in rare cases. So please ignore the above comment from realchild. There are other risks that you should discuss.
posted by docpops at 9:44 AM on February 25 [2 favorites]

Definitely go to a pain management clinic. You are not the first person with chronic pain to have depression and other mental illness; pain and mental illness are often co-morbids. The pain management doctors are trained to treat both. They do good work.
posted by FergieBelle at 12:10 PM on February 26

Please accept my sincerest apologies, anonymous, for wasting your time with my reply. I had not realized then that this issue was better left to those who had the appropriate paradigmatic understanding.
posted by realchild at 9:02 PM on February 26