Posts Tagged 'pain management'

The Jig Is Up

Jeremy Jones’ back surgery didn’t seem to have done much for his pain. He came to me on long-acting narcotics and generous doses of short-acting painkillers to take as needed.

His spine surgeon had nothing more to offer, and it was up to me to prescribe and monitor his medications.

Last month he produced the right number of pills for his random pill count. He didn’t seem surprised when Autumn, my nurse, called him in for a pill count; it is part of the narcotic contract he signed when he first came to our office.

Some doctors don’t accept new patients with pain issues, even if they are in dire need of care for diabetes and other medical problems. Our office doesn’t discriminate like that, but we try to be firm and fair in our enforcement of the office’s narcotics policy.

The random urine drug screens sometimes reveal that a patient isn’t taking the pain medicines we prescribe. The “street value” of these drugs is ten dollars per pill and up.

Other times we find medications not prescribed by us or illegal substances like cocaine – all reasons to stop prescribing pain medications or to discharge the patient from our practice.

Jeremy’s first random urine drug screen didn’t happen.

“I just went before I left the house”, he explained. Several cups of water and an hour later it was almost closing time.

“We’ll catch you another time”, I said casually, not realizing how prophetic that sounded until after I had said it.

Several weeks went by. Then, last week, Jeremy had a morning appointment.

“Let’s have you do that urine drug screen today”, I insisted.

“Oh, I just went while I was waiting to see you. I couldn’t hold it”, Jeremy explained.

“No problem”, I reassured him. “We’ve got all day.”

“But I have an appointment with Dr. Anderson over at the hospital in an hour.”

A quick call confirmed this was true.

“No problem”, I told Jeremy. “I’ll write you a lab order and you can just go to the hospital lab after your appointment with Dr. Anderson. After all, that’s where your sample would be going anyway.”

“Great, I’ll just stop in there, then”, Jeremy smiled nervously.

“Fine”, I said.

I got busy and a couple of days went by. Then Dr. Anderson’s report from Jeremy’s appointment arrived. That reminded me – I had not seen Jeremy’s urine drug screen yet.

Two minutes later I knew that there was no record of a urine sample on Jeremy Jones at the hospital.

I reached over to the keyboard and started typing: 

Dear Jeremy…

A Hero’s Pain

“I don’t know if you understand, Doc, what kind of man this is.”

The man who spoke appeared to be a few years my junior. He was speaking of his father, who is one of my patients at the local Veteran’s Home, where I am a relative newcomer.

“This man fought in two wars and earned two Medals of Honor. He is not going to tell you how much pain he is in, even when you ask him, because he isn’t even going to admit to himself how much he hurts.”

He made a point I actually hadn’t considered before during my tenure at the Veteran’s Home. My patient has metastatic cancer, and the nursing staff asks him every day to rate his pain. His answer is always 2 on a scale from 0 to 10.

As doctors and nurses we estimate our patients’ discomfort through their words and also through their vital signs, facial expressions, posture and other nonverbal clues. But when it comes to treating war heroes, do our usual instruments fall short?

I remember thinking when I admitted the ailing veteran that he seemed so humble and plain spoken. The words “true hero” came across my mind then. I didn’t consider that I might not be able to accurately assess his cancer pain or his level of distress over his terminal diagnosis.

There is a lot of talk about cultural competency in this country. Today I even read in one of the publications of the American Medical Association that several states are mandating that physicians take courses to improve their skills in dealing with patients from cultural and ethnic minorities.

Somehow I think we oversimplify the issue of cultural competency if we focus on only those we think of as minority groups. Our challenge in caring for all our patients is to meet them where they are, to step out of our own world long enough to at least get a glimpse of theirs. We must first meet as human beings before we can begin our medical assessment.

War heroes are a minority, too.

A Real Pain

Why would a toothache bring Ted Larson to the emergency room when he already takes half a dozen morphine tablets per day for his chronic back pain?

Why did Bridget Hall’s fibromyalgia pain seem to escalate after her last doctor gave her long-acting oxycodone?

Is Bob Bachman really in that much pain from his arthritis, or is he sharing or even selling his pills?

Taking care of patients with chronic pain is difficult. Physicians are at the same time told to recognize and treat pain better, and also to be more stringent with pain prescriptions to avoid drug diversion. Our understanding of the physiology and psychology of pain is evolving, as well as our knowledge of the science behind addiction.

As often before I see that some of the things I learned from my clinical professors in medical school were forgotten or even dismissed, only to come back into focus years later.

Thirty years ago I was taught that patients with ordinary low back pain would get better pain relief from modest doses of conventional pain medications if they were also prescribed a low dose of the antidepressant amitriptylene. The reason, as I remember it, was thought to be that amitriptylene made the brain interpret incoming pain signals differently.

Later, other authorities made a big distinction between mechanical low back pain and neuropathic or radicular pain, commonly referred to as sciatica. The focus shifted away from the brain’s interpretation of pain signals in general to whether a pain originated in the musculoskeletal system, like low back pain or arthritis, or in the peripheral nervous system, like sciatica.

When fibromyalgia was first recognized as a disease, there was a lot of confusion about where the pain came from. The name itself suggested that the pain originated in the musculoskeletal system. With the understanding at the time that such pains could be treated with narcotics, many fibromyalgia patients ended up on strong pain medications. We still used medications like amitriptylene and the more modern antidepressants with success, but the thinking was that these drugs worked mostly by improving sleep or treating unrecognized depression. Today we recognize fibromyalgia as a disease involving increased pain sensitivity of the nervous system, and we now have several medications targeting this mechanism.

We have also learned that patients who receive opiates for any kind of pain can develop a fibromyalgia-like intensification of nerve pain associated with ordinary touch, allodynia, or otherwise moderately painful stimuli. This phenomenon is called opioid-induced hyperalgesia. Paradoxically, decreasing such a patient’s pain medication dosage reduces their pain level.

More recently, even chronic musculoskeletal pain of arthritis has been shown to cause a nerve-mediated general pain sensitivity of a similar type. Patients with severe arthritis often experience aching and pain in areas without joint disease, such as skin or muscle tissue.

The practice of my early teachers, who treated most chronic pain as if it were at least in part nerve pain has found new respect and acceptance after many years of neglect as science has finally caught up with their clinical wisdom.

So when Ted Larson, already on chronic narcotics, complains of severe, nerve-mediated tooth pain, his pain is real and may actually be more severe than the same toothache in a person not on narcotics.

Bridget Hall’s fibromyalgia pain may actually have been made worse by the narcotics she was prescribed.

And Bob Bachman’s long-standing arthritis may indeed have made him increasingly pain sensitive. He has never failed a random urine drug screen or pill count. With the new data on neuropathic pain sensitization in patients with longstanding arthritis, it may be time to try him on something specifically for nerve pain, rather than increasing his regular pain medications.

It’s Only Pressure

I was an hour late as I drove into Mrs. W’s driveway. It had seemed impossible to get out of the office, with tall stacks of charts to be signed and three days of unanswered phone messages to take care of, but this housecall needed to be done. A cancer patient, Mrs. W., had asked me to come out and discuss her pain management with her.

 
My stress had eased a little as I drove along the pretty country road to her house. As she greeted me from her sick bed, I sensed her calm. I sat down, apologizing for being so late. She spoke slowly and with great dignity. She weighed her words as if each one cost her a great deal of effort to produce, and her face showed something between pain and determination.

 
“I thought I’d be asking you for some stronger pain medication today,” she said, “but then I remembered the wise, old doctor who delivered my first child. He told me I would feel no pain, but a great deal of pressure, and that’s what I remembered, and that’s what I felt throughout the whole delivery. And I think that what I feel now isn’t quite pain, it is only pressure, and I think I can handle it at this point.”


“You mean that you understand the pressure, you know how it behaves, and you aren’t surprised by it or controlled by it?”
I asked.

 

“Yes,” she answered, “that’s it, I understand it, and I’m not afraid of it. I won’t need any medication from you today, and I still have the other ones you gave me.”

 
We spent almost an hour talking and going through her exam and her different treatments. With her slow, careful way of speaking, and the obvious inner strength of her whole being, I wasn’t there to do anything to her or prescribe anything for her. I was there to listen to what she had already figured out. And I was there to learn.


Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

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