The overweight 72-year-old woman whom I saw in clinic was miserable because of osteoarthritis in both her knees.
Like so many other patients with these complaints, she had tried numerous NSAIDs that either didn’t help or came with intolerable side effects. Knee injections with corticosteroids, as well as hyaluronic acid, were both disappointing failures. Like most 72 year olds, she didn’t want knee replacement surgery if she could avoid it.
After this dismal track record, I tried to find an analgesic that would help without causing dreadful side effects. Neither tramadol nor hydrocodone had worked well, so at her last visit I prescribed oxycodone. I prescribed enough of the medication for her to take four tablets a day. Despite this, she came back to see me and she was still miserable, unhappy, and discouraged.
I investigated the reasons for the latest treatment failure, and what I found out did not please me one bit: Even though the prescription was clearly labeled with instructions to take up to four a day if needed, she was taking only two tablets a day.
Normally, when I find patients underutilizing pain medication, it is because of GI side effects, cognitive impairment, or fear of addiction. My patient didn’t have any of these problems. She was afraid to take four tablets a day because the pharmacist told her four a day would put her at high risk for GI bleeding.
"Why did you ask the pharmacist instead of me?" I bleated plaintively. I try really hard to never get irritated with patients, but sometimes patients find creative new ways of pushing my buttons, despite my attempts to maintain a sunny and supportive countenance. Even as the petulant query went whizzing out of my mouth, I regretted asking it, and I already knew the answer.
Patients would much rather ask the doctor than the pharmacist, but the pharmacist is readily accessible. The patient can just sidle up to the counter at the pharmacy. After a few minutes the friendly pharmacist speaks with the patient face to face – and free of charge!
By contrast, it is almost never so easy to speak with the doctor. A patient has to make her way past the answering service, the nurse, and the practice administrator. After those initial hurdles, the patient has to wait hour – or even days – for a reply. Like it or not, if we aren’t easily accessible to supply answers to our patient’s questions, someone else will be happy to do it for us.
Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.