I’m a pediatric oncologist, but cancer is not always the most serious problem my young patients face. Currently one of them, a 14-year-old boy, his mother, or both may be opioid addicts. I may be enabling their addiction.
Tragically, their situation is not unique. Adolescent patients are at risk for addiction from opioid pain medications just as adult patients are. But pediatric patients are overlooked in this war against opioid addiction. No policies protect them or those caring for them.
Usually pain is short-term, and only limited opioids are needed. Most providers, including those caring for children, are trained in acute pain management. Patients and providers are also protected by policies limiting the prescribed amount of opioids for acute pain.
Occasionally, complications such as bone, muscle, nerve damage, or scar tissue development result in longer-term, chronic pain. These complications happened to my 14-year-old patient, and happens with enough frequently that cancer patients are often exempt from prescription limits.
A person’s ability to cope with pain varies greatly. Some patients with identical complications manage with minimal narcotics and instead use lidocaine patches, ibuprofen, physical therapy, and mind-body awareness to continue their lives with resilience. Others, like my patient’s mother, insist nothing but opioids work.
Most doctors avoid chronic pain management and worry about the liability of authorizing repeated narcotic refills. I worry, too. In this case of this patient, I worried particularly after an online opioid prescription registry showed that in one month, my patient had filled my oxycodone prescription, as well as other prescriptions, four times what I had prescribed.
I cannot tell who is taking the pills — my patient or his mother. He does not know what medications he takes when they are handed to him. However, he frequently comments that his mother cannot wake up early or drive sometimes because of her pills. Indeed, our office knows she may be incoherent and forgetful if we call in the morning.
Prescribers who suspect an addiction usually refer their patients to a specialist trained to manage chronic pain. By referring the patient to a pain specialist, providers remove themselves from the opioid liability while preserving the relationship to treat other health issues. Unfortunately, my state, New Hampshire, which has the nation’s second highest opioid overdose death rate, has no pediatric pain clinic. None.
Adult chronic pain specialists are not trained to manage pediatric patients even if they are adult-sized. Children cannot sign opioid contracts or be held directly responsible for their care. Chronic pain is as much psychological as physical, and adult pain specialists are not prepared to manage the interdependent psychosocial complexities between children with cancer and their traumatized and anxious parents.
My patient and his mother went for a single visit to the closest pediatric pain clinic three hours away. Physical therapy, non-addictive neuromodulators, counseling, and opioid weaning were recommended. His mother was offended by the counseling suggestion, unhappy opioids were not prescribed, and refuses to return to the pain clinic. I cannot force them. It is too far and the cost is not covered by insurance.
I suggested medical marijuana, which can improve coping with pain. Professionally, marijuana is easy. Physicians do not prescribe marijuana. We only certify a diagnosis. The state is responsible for determining eligibility, investigating abuse risk, and dispensing it. I have no responsibility or liability in my pediatric patient’s marijuana use. But as a pediatric opioid prescriber, I am fully exposed.
Although his stuffed animals talk to him when he uses marijuana, he still has pain and his mother still demands oxycodone. I expect him to have pain, but I have no idea how bad it is, how many opioids he needs, or who really takes the pills.
Some suggested treating only his cancer and not his pain. I would follow that suggestion, if pain management were available elsewhere. But it is not, and I know he has painful complications from the chemotherapy I gave him.
Others suggested entirely refusing to treat him because of his non-compliance. But he is not solely responsible for his non-compliance. And, it is unethical to deny him cancer care when the next closest pediatric oncologist is three hours away and outside his insurance network.
So I do what I can. I cannot provide ideal chronic pain care. Instead I focus on minimizing the damage that could be done to him, his mother, and myself.
I am scared for my patient and his mother and their addiction risk. I am scared for myself and other providers who lack guidance and protection in pediatric chronic pain management and the inadvertent role we may play in addiction. I am scared because writing prescription after prescription feels wrong, but I see no alternative.
So I am curing this boy’s cancer at the cost of his life? How many other pediatric patients are like him, successfully battling a disease and yet falling through cracks of our healthcare system into a deadly pit of addiction?