I felt guilty the day I decided I could no longer prescribe opioid pain medications to patients with severely painful wounds. I didn’t prescribe narcotics very often since that’s a bad way to treat any chronic pain, but it is sometimes necessary in acute vasculitis and pyoderma gangrenosum (PG) which can be among the most painful conditions imaginable. Those patients need pain management immediately. However, as a part-time practitioner, the 8 hours of training required to prescribe opioids (and the additional complexity of prescribing) made me throw in the towel.
It was impossible to get patients into a pain management doctor quickly, and they were booked up from the influx of patients with no other options. To keep patients from feeling abandoned, I arranged for the ones with the worst pain to be hospitalized for pain management (although heaven help them if their insurance required prior authorization for that). That may have been a good plan for the pain, but many of those patients need expensive immune-modulating infusions which are almost solely available as an outpatient due to cost, or high-dose steroids which I COULD prescribe but which the in-patient pain management physicians were not comfortable providing. (“I can’t give the patient high-dose steroids – you don’t have a biopsy providing that they have vasculitis.” They were not impressed when I said, “I have EYES.”) You might ask why I didn’t send them to one of the TWO academic Dermatology programs in my city. I TRIED. The only way to get a patient with acute vasculitis or PG admitted is through the emergency room. However, an excruciating, strange looking “rash” does not generally interest an overwhelmed Emergency Medicine physician when a Level 1 trauma center has no available beds. I typed out a script for patients to say when they arrived in the ED about their “chills and fever” and whatever else I thought would get attention – and then prayed that Derm would be consulted and that the Derm resident would know what they were looking at. My former academic credentials were no help. After several wasted days in the hospital with either no Dermatology consultation or a “dithering dermatologist,” I finally told one patient to sign out “against medical advice,” so that I could at least prescribe him steroids.
If you don’t believe me that this problem can be serious, read this post from 2022, “And I Only Am Escaped Alone to Tell Thee” – A Patient’s Experience With Excruciating Pain and Redemption”.
All that is old news. I am on a rant today because they made the 8-hour training on opioids mandatory just to renew your DEA license – even if you do not prescribe opioids. So, those of us who practice part-time and don’t prescribe opioids have to take an 8-hour course it or lose our DEA license to prescribe things like antibiotics and steroids. Here’s some information from the AMA on how to comply with the MATE Act. Don’t bother to message me about statistics on the opioid crisis. I watch the news. The current reality is that short-term use of opioids for good reasons is darn near impossible and I am fed up with bureaucratic “good intention” requirements that have unintended consequences – like making doctors decide to just RETIRE.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.
