Kevin, M.D. - Medical Weblog

Something's not quite right about that story. The poor drug addict was spending $400 per day on oxycontin? A previous doctor was giving him prescription drugs, but no other would? In my limited experience in a suburban area, most "straight shooters" have no trouble getting in to see the pain management guys and getting long term fentanyl patches or oxycontin. Wouldn't it have been a lot cheaper to pay a co-pay? Even 5-10 co-pays?

Methinks he left out part of the story. (and my sister is reovering from a narcotic addiction, I am not unsympathetic).
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Yes, I was none too pleased with the "blame the doctors" tone he took. Why is it always the doctors' fault? I've read several recent articles that portray the doctor who wrote the narc scripts as the source of the drug dependency. Isn't the patient, the patient's pain, and the patient's way of presenting their pain (+/- lies and manipulation) ever to blame?
 

I'd say he fit the stereotype pretty well given his self escalation of doses.
 

Mrs. Hooper's "Whole story" doesn't begin to uncover the potential complexities associated with Andrew's, and other similar stories.

Why people become "Addicted" and what that relationship to their pain treatment history happens to be - is never a simple tale.

I'm going to 'throw' a couple of things into these comments - worthy of consideration.

Andrew started out getting the same type of haphazard pain treatment that usually is insufficient to cover a patients needs - and actually predisposes those same patients to early and rapid development of tolerance [ and potential addiction ]

1- Using rapid rise blood level type drugs [ Percocet, demerol, Tylenol #3, vicodin, etc. ]

2- Interruptions in treatment - based on lack of attentiveness and understanding on the part of the physicians, along with public policy pitfalls;such as not having regional or national plans implemented to insure that pain is treated as a disease-not just a symptom.

Add to this the 'demonization' of oxycontin, and the belief, on the part of most doctors, that methadone should only be used for addiction treatment [ and not for managing chronic pain ]and you have the perfect ingredients for the development of future problems.

It is unlikely that most readers of this story are ever going to fully understand these issues. At the same time, the medical profession hasn't done much to help undo the myths and prejudices surrounding opioid prescribing.

The orthopedic community, in particular, has not responded properly to the post-operative pain needs of their patients.

This is not an irresponsible accusation, based on my own prejudice. It comes from 20 years of close observation and interaction with the orthopedic community.

Its as if a radiologic improvement in fracture alignment was justification for walking out of an operating room with an inflated feeling of accomplishment.

Often times it isn't their fault - their daddy teachers - never taught them much about human suffering.

Andrew Hooper may have been genetically predisposed to addiction - if he really is addicted. I'm not so sure from reading this story that he wasn't really a pseudoaddict who got mislabelled after which it became convenient to just take more and more medication-for fear of never being able to get it again.

In any event - he needs our help and our compassion. For a couple of nations that have spent billions on liberating Iraq and drinking gin in India - you'd think that a little more spent on addiction treatment wouldn't be a problem.

And when the funds are properly allocated - here are some ideas:

1- Train health care workers to use the proper pain drugs right from the outset.

2- Start divesting doctors of their ridiculous beliefs, such as, for example, that opioids shouldn't be used in- and do not help - patients with neuropathic pain; THEY DO.

3- Prescribe long-acting controlled relief meds from the beginning - such as oxycontin, ms-contin.

4- Appreciate how genetic influences modify pain-and the spinal cord.

5- Treat suffering - not just pain.

These things will be a good start.
 

Dr Mangino:
A few points:

"Interruptions in treatment - based on lack of attentiveness and understanding on the part of the physicians"

If the story is true then clearly the handoff from a retiring doc to an accepting doc was a fumble. I know this is Britain but in this country there appears to be a fear by some docs to prescribe adequate pain meds WITH CLOSE MANAGEMENT. Personally, I feel methodone is a great drug for pain once I ally the patients misconceptions about the drug. Of course, unlike you I haven't had the DEA knocking on my door(yet). One issue I have in my city is "pain specialists". Unfortunately what they seem to do (if you can even get my patients in to see them), is place them on narcs then ship them back to the PCP with little if any follow up. Hell, I can manage that,what do I need a pain specialist for? Presently, unless I feel some sort of block/stimulator needs to be done, I manage things on my own. I think you need to look long and hard at your own specialty, because in my experience most PCP's find "pain specialists" to be as much of a hindrance as a help (unless the PCP refuses to right for narcs and sadly I see that too). No offence but I getthe impression alot of these guys entered your field for the $$$. With respect to orthopods, I have also had the opposite problem. Orthopods who place patients on oxycontin right after the OR. I can't tell you how many times I have seen resp distress/failure due to a narcotic naive patient given 20 mg a oxycontin right after surgery. If you have a recent article that explains this behavior I would apprecite it. I have asked the orthopods on this one and it seems to be more custom than anything else. I have gotten to the point of placing all of their patients on tele/pulse-ox "just to be safe".
 

Dear Anon 10:54,

This is a tremendous letter. I agree with what you say, and sympathize with what you deal with.

I want to give a meaningful reply-and appreciate your asking my opinion.

Allow me to reply a little later-today.

For now,I want to clarify that orthopedists do well at what they do best. It's a tough field-under a lot of scrutiny. they can't be all things to all people.

Having said this - they do tend to be a bit dismissive of longer term painful conditions in addition to viewing the presence of persistent pain as a sign of failure. This is especially true with regard to post-operated cervical and lumbar conditions.

This attitude tends to be more prevalent in the larger eastern cities-here. If you go to Iowa or Seattle-it's a different ballgame.If you're at a medium size Philadelphia hospital or the 'old days'at Hahnemann - you were doomed to be ignored-period!!

Briefly-with regard to post op OxyContin, we have to consider the type of anesthetic agent, amount-if any-of intraop opioids given iv, and the subtleties of O2/CO2 response curves in the post anesthesia period, and sophisticated things of that nature.[ as I am sure you know ] But-given the simplicity of your question-the simple answer would be that maybe 20mg. of oxy was a little too much for that patient.

In general, during the first 24-48 hrs post op PCA or IV stuff is better than an oral opioid. It was with injured-yet ambulatory - patients that I was focusing when I claimed that long-acting agents are better than short. Obviously, not all situations are ideal.

Be that as it may-10-20mg. of OxyContin, in most patients-even opioid naive- should not cause any degree of respiratory impairment that I would consider as dangerous-in my experience over about 12 years of prescribing this medication on a routine basis to about 340 people every two weeks or so. The 340 patient population has been 'turned over' many times during those years-and I cannot remember even one complication. That speaks to the relative safety of this medication in the ambulatory chronic pain patient. Post-ops are different, for many reasons.

I'll write a bit about my favorite subject-'Who is a pain specialist'? - later on.

Hopefully that will answer the other part of your inquiry.

By the way- I mean no respect, in particular, to your system or British history. It must be tremendously difficult for you to manage these issues with finances and so forth.

I hope that I can say with the folks over on your side ---

There will always be an England.

Best wishes and thanks.
 

Dear Anon 10:54

To answer your question - I believe that to really practice pain management one must have a tremendous interest in really reading and examining the literature - and - above all else - love what he is doing.

It isn't a qusstion of just specialty training in a related field - which certainly is an advantage [ anesthesia, neurology-surgery ] - but also loving to learn about the intricacies of pharmacology and genetics of pain and cell science.

Next of all- be willing to accept and deal with the suffering of the patients and try to understand their dilemma's.

It isn't 'dropping out of the OR' to do a nerve block-and not tending to the patient as a special entity.

We, in this country, have a whole medical-industrial complex developed around interventional techniques-which often don't work.

Patients become collectively disenfranchised as a result of this approach.

If they don't get better-they become classified as drug seekers and malingerer's.

I agree with your comments. I don't have all of the answers. I don't believe injections are the long-term answer to the problem of chronic neck and back pain.

There are some interesting recent articles in the last couple of months from several journals-NEUROSURGERY may 2006 vol 4 number 5 380-387 about neuropathic pain and in Anesth Analg 2006;102:1768-1774 about opioids in neuropathic pain.

In addition, Anesthesiology 2006; 104: 1283-92, about early gene formation after spinal nerve root injury.

Hopefully, you will find these interesting.

The latter article calls into question the efficacy of spinal fusion, in light of the fact that most chronic pain becomes a 'central' phenomenon.

Best wishes.



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Thanks for the info. I will look at the articles.
 

Here is something I don't understand. If an OS is doing major (joint replacement) surgery many times each week.

1. Why don't they then get educated to proper pain control for their patients?

2. Why don't they just admit this (pain control) is out of their specialty and turn those paitients over to a pain specialist following surgery.
 

" Why don't they just admit this (pain control) is out of their specialty and turn those paitients over to a pain specialist following surgery"

Many do turn their patients over to PCP's/hospitalists after surgery. A pain specialist's wait is often 3-6 months (if you can see them at all). You want to wait that long. A good internist/op should be able to manage non-long term issue on their own.