To prescribe or not to prescribe… (in chronic pain… and elsewhere…)?

Most medical doctors close a consultation by a drug prescription, even if some doubts exist about the treatment efficacy. The aim of this paper is to open a discussion on the questions underlying this urge to prescribe and to make some proposals for the clinical practice. Firstly, the psychosocial factors which may question the relevance of the prescription will be discussed. These elements (unrealistic treatment expectancies, distrust or anger against caregivers, multiple earlier treatment failures, or a relatively balanced situation) might threaten potential treatment benefits but may be difficult to identify and take into account. Secondly, some caution has to be made if the clinician decides to prescribe despite these psychosocial contraindications. It is then important to discuss with the patient the meaning of the treatment, its concrete aims and its practical modalities. Finally, observing that concluding a consultation without any prescription might be very uncomfortable for the caregiver, asks questions about the symbolic meaning of the prescription: need for the patient to be mothered, need "to keep up" for the doctor, biomedical reference frame observance. We conclude that, in spite of the anxiety raised when no prescription is made, the absence of prescription might paradoxically reopen the therapeutic process. Observing that pain may resist to the treatments allows a move towards broader objectives than symptom control. Such a change is possible only if it is recognised that the biological and psychosocial conditions of efficacy of the treatment are not, or will never be, optimal.