Monday, March 10, 2008

Yet another reason to be ashamed to be a doctor

A number of years ago, a lady came to me with a diagnosis of fibromyalgia. She was in significant pain, was on long term disability and had tried all the usual nostrums for fibromyalgia.

After some discussion I put her on a small dose of methadone. Because methadone blocks NMDA receptors, the theory is that it might be a good medication to try in fibromyalgia.

Now I have not been able to duplicate this success with many other patients but she did fabulously. Her pain decreased, she slept better, she was more functional. She had at that time been off work for many years so going back to work was not really in the cards and her disability insurer didn't seem too unhappy with that.

Over the year or so I followed her, she increased her medication slightly but stabilized on less than 10 mg per day. Her family doc who did palliative care and had a methadone licence then took over her care again.

About a year ago I got a new referral to see her. The letter said that her family doc, had retired and that her new doc didn't have a methadone licence.

Methadone licences to treat pain are relatively easy to get in our province; in addition it is possible to get a licence to treat only one patient. I phoned her doctor and told him I would send a letter supporting his application for a patient specific licence. He said he really didn't want to do that.

Several months later I actually saw the patient again.

She told me that since her old family doc had retired, she had been making the rounds of family docs who were taking new patients. All of them flatly refused to see her after learning she was on methadone even though it was clearly for pain and not for addiction. The last guy, the one who referred her to me said he would be happy to look after her medical concerns but would not prescribe methadone or any narcotic for her.

While certainly prescribing narcotics is controversial and little bit of a hassle, here we have a patient who is on a stable dose of medication that is clearly benefiting her and yet we have a series of doctors who refuse not only to look after her pain but refuse to even take her on as a patient.

I can think of a few medical conditions that are a lot more of a hassle to deal with than a patient on a stable dose of narcotics. Insulin dependent diabetes and anticoagulation come to mind. I wonder how many doctors turn down those patients. (Sadly I suspect quite a few).

As I said in my referral letter, "this is a sad reflection on the medical community".

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