Dear Patient

I do believe that you are in pain; I can see it in your eyes, your furrowed brow.  I can see it in your hesitant gait, the cautious way you get up and down from my exam table.
But this is the first time I’ve met you. I don’t have your medical records.  I don’t know anything about your kidney or liver function, whether or not you have heart disease or diabetes.  You don’t know either, which is not unusual.  Many people come to me for the first time without a list of medical conditions or current medications.  We can work it out.

You can expect me to take a thorough history, do a complete physical exam, and request your old records.  But I am not going to give you a prescription for narcotics today.

It’s not that I don’t believe what you’re telling me:  I believe you when you tell me that ibuprofen doesn’t work or that you are allergic to it.  I believe you when you tell me that all your other doctors have given you narcotic prescriptions.  But I don’t know you yet, don’t know your whole medical picture.  Narcotics are potentially beneficial and potentially risky.  Dependence is a disease that is very common, and very difficult to treat.  You should not expect me to take such a risk with your health at this point.

It is possible that your disease, be it chronic pain or opiate dependence or both, does not let you understand that.  You may feel angry, depressed.  You may lose your temper, behave inappropriately.  If I suspect a narcotic use disorder I may offer you a referral to a local expert.

You may not like this, and I may be totally off base, but I have to give the best advice I have, whether you like it or not.  I hope that you will be able to see this as an act of kindness rather than another obstacle in your efforts to get what you think you need.

I will continue to try to help you treat your pain, but I will choose medications for your pain and your other conditions based on what is likely to give the most benefit for the least risk.  Sometimes this treatment may include narcotics, sometimes it will not. All I can do is advise and hope that my advice is good, and that you will follow it to the best of your abilities.

To you health,



  1. Kevin Nasky

     /  August 16, 2011

    Well said. Brilliant.

  2. IanR

     /  August 16, 2011

    I have a question about this. I had a friend who a doctor pegged with having anxiety, and gave him benzodiazapenes right off the bat. Given they are addictive and abuseable, is that the best prescription? Or should the doctor have tried something else first?

    • While I certainly have nothing to say about a particular case, the general idea is neither unusual nor improper.

  3. LM Alden

     /  August 18, 2011

    Dear doctor, Obviously you don’t believe that Im in pain, you didn’t take the time to read all my medical records I took the trouble to have faxed over to you weeks before my first appointment with you and prescribing 10 narcotic pain pills or even Ultram to tide me over until after my lab work comes back in and we can meet for the second time to discuss my chronic pain and chronic disease which has been well documented for over 3 years in those records I kindly had faxed over to you from all my previous MD visits that you couldn’t be bothered to read is out of the question because you think Im med seeking. Even though you would have noted in my previous MDs notes that that I manage my autoimmune disease on 1 vicodin at night to sleep and a bottle of 90 lasts me 4 months. And that of the three refills one was never used. And that I prefer asprin and motrin to narcotics but sleep is impossible because I hurt. And that I was using 100mg of benadryl and a shot of tequila at bedtime to try for four hours of rest and that my last Rheum whom Ive seen for the past three years every three months faithfully had to convince me to try the vicodin in the first place. And that I have refused the sleeping pills she offered. Or the pain patches. Which is why Dr, I come away with mistrust and an even lower opinion of doctors in general and you in particular , thereby ruining our nwly established Dr /Patient relationship irrevocably. But Im too tired and in pain to look for yet another I might be able to establish a working relationship with. Because just as you have to try (or should) trust me I have to try to trust you. And which is why I would choose to self medicate with whatever is at hand such as alternative, homeopathic, herbal and even foreign medications to relive that pain you say you see in my eyes and on my brow but cant be bothered to treat just yet because you don’t want to prescribe me a weeks worth of meds. And I wont bother to tell you about what Ive tried between our visits since I really don’t think you care to hear about my pain, what works ,and what doesn’t . It seems you care more about your prescribing track record. And have lumped me in with drug seekers and abusers which, if you had read my records, you would have seen continuity of care with the same doctors ,and meds year in and year out – something a good doctor would know is not the pattern with drug seekers. They doctor shop. Go somewhere 1-2 times and move on. Visit every ER in town. Have sporadic care. A good doctor would know that. Which makes me worry about your experience , diagnostic ability, and skill level. Ill stick with tequila. And asprin. And the ER when I feel like Im truly dying.

    • ZenHousecat

       /  August 19, 2011

      Mr./Ms. Alden,

      No, he didn’t (and won’t) take two hours to go through the 200 pages of records scattered from your internist(s), ER docs, general surgeons, psychiatrist, psychologist, orthopedist, neurosurgeon, endocrinologist, neurologist, rheumatologist, physiatrist, gastroenterologist, infectious disease, and chronic pain specialists–stop me if there’s anyone I missed–until you actually show up in clinic to be evaluated.

      Because if you don’t show up, he’s wasted time that could be better spent with his other patients, or with his family, and hasn’t been compensated for it.

      *When* you appear to his clinic, you’re entitled to a block of PalMD’s time to get to recount your history, receive a good physical exam, and have appropriate lab tests drawn and imaging ordered. He will then review your records after clinic, likely at home, on his “off” time. He’ll then, more likely than not, contact your previous physicians to get caught up to speed on any issues that may not have been included in the records. *If/when* you return for followups, the process of building a therapeutic relationship can go forward. That’s. Just. The. Way. It. Is.

  4. Mary

     /  October 22, 2011

    Here is what I don’t understand.

    If a patient showed up in your office for the first time with a raging lung infection, or a broken bone, or clear asthmatic wheezing, you would prescribe whatever was needed to ameliorate those issues…regardless of whether those drugs had side effects. You would write a scrip for antibiotics, or prednisone, or whatever else might help. You would not deny patients medication. You would understand that the patient’s immediate condition necessitated immediate treatment.

    However, you’re saying that when you have CLEAR evidence that a patient is in pain, which is a legitimate medical condition as much as a lung infection, and has clear detrimental effects on quality of life, you will deny them the medication that is necessary to treat their condition because, quote, you don’t know them.

    Drug abuse is a major issue. Nobody is saying that the first time you meet a patient you need to turn over a scrip for 500 morphine pills. However, it is disingenuous to deny patients who are in immediate discomfort based on the fact that others abuse drugs. You could prescribe a two day supply and then ask to see them again or refer them to a pain specialist. You could do a lot of things besides just turning them away. What exactly do you expect a patient who is in pain to do, when you won’t help them? I’m not asking that to be facetious. If a patient is in enough pain that they cannot carry out their daily activities and they cannot get relief, what are they supposed to do?

    • Go to the ER.

      • Mary

         /  October 25, 2011

        That’s a nice way to blow off my comment, but really dismisses the fact that by ignoring and refusing to properly medicate pain, you’re not properly treating patients. I think I brought up a good point…doctors routinely prescribe medications with significant side effects and the possibility of longterm dependence (steroids, anti-depressants and benzos, to name a few) but when it comes to pain medication, which certainly isn’t more dangerous than those, they can’t be bothered.

        So you would suggest that a patient with chronic pain should spend $50 (or whatever their copay is) to go to the ER…which is already overburdened with individuals who use the hospital for primary care…spend up to eight hours waiting, in pain (since pain will not be something that will be triaged at the front of the line) and then…see a doctor who might share your philosophy? If a primary care doctor refuses to give patients necessary medication because, quote, he doesn’t know them, what is to stop an ER doctor from saying the same thing? If I show up in the ER and say “hey, I have migraines/fibro/arthritis/back pain” or another problem that an ER doctor is not equipped to diagnose or verify–do you honestly think they’re going to address my pain?

        And how will that solve the patient’s problem when that scrip runs out? Or would you suggest that they permanently camp out in the ER so that when their eight or ten hour pain pill wears off, they can go through the line again?

        Dismissing chronic pain, or suggesting that patients should live in crippling pain until you decide you “know them” is not upholding your end of the Hippocratic Oath to do no harm. If you wanted to avoid doing harm, you would make sure your patients were not leaving your office in pain.

        • Sorry, I typed while cranky.

          Best care have to be based on good medicine and science, governed by compassion. If someone has a bone sticking out of their leg, they will obviously get pain medication from me while they wait for a ride to the ER.

          But someone who comes to me reporting severe pain, but without any specific findings and no medical records, if their pain is severe enough that the feel they need narcotics, i’ll send them to the ER as the pain could represent serious pathology that I’ve failed to recognize.

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