I’m on tour to promote Dreamland, and along the way I’ve have had conversations with parents of addicts, doctors, public health employees, and the public in general.
Often the conversation revolves around why this is a problem, and why it continues to be — if we see that massive 
prescribing of pain medication has clearly led to heroin addiction.
This letter from a nurse practitioner at a chronic-pain clinic in a mid-sized town in the western United States helps explain.
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The clinic I work at has a reputation for liberal opioid/opiate prescribing and there is a culture of dependency and codependency that has been instilled by the owner. Prior to coming to this clinic I worked in a psych and drug rehab hospital in a rural part of the United States for five years. I saw all the patients that became addicted first by pain medication or other means. It is a struggle for me everyday to know that I now contribute to this problem.
Every day I try to have the conversation with patients on what it would be like to get off the medication. Most patients tell me no one has ever had that conversation with them. It makes it that more difficult because then I look like the jerk that wants them off their meds when every provider before me told them they would be on pain medication their entire life.
I have developed a reputation as being a terrible provider by many of the clinic’s patients. The front desk asks my medical assistants what it is like working with me since all they hear is terrible things about me.
Many people talk about going after to the doctors to stop this opioid epidemic. The problems I see are patients with terrible insurance that doesn’t cover comprehensive pain management. What I am stuck with is a person with limited resources and a 20-minute appointment and sometimes all I have left is medication. Most of my patients get upset with me, and laugh when I give them breathing exercises to perform.
I don’t start many people on pain medication but I have kept many people on medications that I sometimes don’t feel comfortable prescribing. I go out of my way to try to find alternatives to pain medication for my patients. My hope is that one day pain management is taken out of primary care completely. Pain is too complex to dealt with in a 20-minute appointment.
The other issue is patient satisfaction. That is a huge issue in emergency departments. I have spoken with many ER docs and it seems a lot of the care is driven by customer satisfaction. Doctors fear bad reviews from patients. I think this drives a lot of the pain medication prescriptions in EDs. Because of this, I have seen some of my patients get opioid/opiate prescriptions for relatively minor medical issues.
I have found some positives. Most patients I discharge for multiple violations of their medication agreements never come back. The ones that do often turn out to be my favorite patients. When I don’t worry about prescribing controlled substances with patients then we often get to work on lifestyle changes like better management of their chronic conditions or quitting smoking.
Anyways… I probably have a lot more to say but that seems like enough. Thank you for your time.
