Treatment of chronic pain puts doctors in a no win situation

First do no harm.

Treat every patient with respect and dignity.

These are values I try to live by and incorporate into my daily work.  Treatment of chronic pain is the scenario that puts me and every practicing primary care physician in a no-win situation regularly in the office. To try to make physicians feel more comfortable treating pain most states have tried to legialate guidelines.  They have been less than reassuring.  In Washington all I have to do to comply with the guidelines is to follow a comprehensive 4 page list of recommendations. Washington is helpful by also legislating recommended responsibilities for patients.

For physicians they state: “Subjective reports by the patient should be supported by objective observations.”

For patients they state: ”The patient should demand respect and expect to be believed.”

How the physician can be expected to “believe” the patient, yet not rely only on subjective history by the patient but have objective evidence often for problems where no objective evidence exists, is the inherent flaw in trying to define and regulate pain management.

Add this to the environment in which we practice.   Each week for the last three weeks I’ve had a young male, ages between 21 and 25, present to the office asking for help in one way or another for addiction to Oxycontin.  In each case the patient had never received a prescription from a physician for an opioid.  Each time they had taken the drug first when supplied by a friend or coworker, either for treatment of pain from a minor self-limited problem, or for recreational use.  Each time there was a quick progression, over weeks to months, from occasional use, to regular use, to daily use and addiction.  So far in each case, thanks primarily to supportive parents and patients with a strong desire to get treatment, I’ve been able to aim them towards a treatment facility where they could get help.  I’m not a naïve or casual observer of the current prescription opioid epidemic in America.

I’ve posted several times on this and related issues: Can’t find a doctor to prescribe pain meds? and Oxycontin: What’s the big deal?

Still I continue to be amazed at how readily available Oxycontin has become for recreational use.  This is a medication that is a Schedule 2 controlled medication, meaning to get a prescription you need to have a written prescription on forgery resistant prescription pad paper, and cannot get a prescription with refills.  Despite these attempts at preventing abuse, the drug seems to be easily available for abuse. To add urgency to this problem is fact that accidental overdose from prescription opioids is at epidemic proportions.

Without any doubt the posts on DrPullen.com that have had the most interest have been the posts on pain management.  The most passionate comments have been from patients with chronic pain who feel that their need for opioid management of their pain is underestimated, undertreated, poorly understood, and that they are treated without compassion or respect.  Unfortunately some of them are right, but the incredibly widespread abuse of prescription opioids at this time puts physicians in an impossible position.  We are supposed to both show compassion and adequately treat non-malignant pain with the same drugs that professional patients and opioid abusers seek to get prescriptions.  All this is in the face of treating a condition, pain, for which there are only subjective scales to quantify and for conditions which often are diagnosed strictly on what the patient tells us, without any objective evidence of their existence in a given patient.

You could compare this to being asked to look at a young person and sell them alcohol based on their general appearance to decide if they are 21 or not, and if you guess wrong, having the possibility of being punished for wrongly selling to a minor.  There is no state authorized ID card to tell us which patients who look like they have pain from fibromyalgia, interstitial cystitis, peripheral neuropathy, lumbosacral disc disease, or lots of other conditions.  We are simply left to do our best to make a good judgment.  Patients are just left in pain.  This whole scenario stinks.

I’m not alone in struggling with this dilemma.  An FDA policy called REMS (Risk Evaluation and Mitigation Strategy) for opioid prescriptions has been a unique approach to addressing this problem. The complex issues related to this policy are nicely discussed in a Pharmacy Practice News article for those of you interested in the details of this debate, but the bottom line is that no one has figured out an approach for the prescribing physician to use to confidently use opioids to help patients manage pain without inadvertently being deceived into prescribing opioids to those patients seeking drugs to sell or abuse.  It’s unlikely that regulations and legislation will provide helpful tools to address this mess.

Most physicians have become really defensive in response to this difficult if not impossible situation. In Pierce County, WA, where I practice, it is nearly impossible to find a primary physician willing to accept a new patient who requests continuation of prescriptions for significant quantities of opioids for pain management.  It’s a shame that we have reached this impasse in care of pain in our country.

Edward Pullen is a family physician who blogs at DrPullen.com.

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  • Leslie

    The main problem is that doctors do not have enough education about pain management. There are other categories of medicinal pain relief besides opioids.

    I have chronic pain. Traditional painkillers did not help. Then I went to a pain management doctor. In the first few minutes of the exam, he said that my pain description sounded it was nerves causing the problem. He prescribed me some anti-convulsants because of the nerves, muscle relaxants, and sleeping pills for nighttime pain. This regimen was enormously successful for me. None of these medications are controversial.

    The way it was so easy for a specialist to come up with this regimen really made me wonder why none of the primary care or orthopedic doctors I saw could think of it. I say this not to rail on doctors, but to highlight the need for more pain education.

    • ninguem

      It’s called “making the diagnosis”.

      I had someone come in to my primary care office, under the care of an anesthesia-based pain practitioner, who had been treating the patient for neuropathic pain. The patient had become toxic from the anticonvulsants and antidepressants. Patient hospitalized, released, sent to me for follow-up. Patient wanted another opinion, and hospitalist obliged.

      To my exam, it looked like a simple bursitis. I treated as such. Steroid injection and physical therapy.Pain gone.

      We weaned off the antidepressants and anticonvulsants, patient is much brighter mentally and remains pain-free.

      The cynic in me figured placebo effect, but two years later, pain is still gone. I now have a very vocal patient sending friends to me.

      I’ve been around the block long enough to know another thing. The reason I looked so smart, is because one diagnosis was entertained, one treatment pathway was taken, and failed.

      I’m not doing that.

      Time for plan “B”.

      In this case, it worked.

      Next time, I’ll be the one with the failed plan “A”.

    • buzzkillersmith

      Education in this area does little good. See my post below.

  • docguy

    Leslie, it’s not all about education. When the federal government shows up at your office and says that your prescriptions have been used fraudulently even if you saw the patient, examined them, and felt a need for pain medication was indicated, the doctor is sure not likely to do it again.

    I’m just happy that I don’t treat chronic pain, because it seems to be a nightmare to my friends who do.

  • Greg

    Leslie – I’m glad the anticonvulsant/muscle relaxant/sleep medication worked for you, but I can’t tell you how many patients I’ve seen who are already taking these medications continue to have severe pain. Sometimes you really have to prescribe opiates long term to control a patient’s pain, but given that doctors face frequent fraudulent requests from drug addicts as well as potential loss of license/malpractice/arrest/jail time for agreeing to these requests, most doctors are going to think twice about jumping headfirst into managing a patient’s pain.

    The number of patients who would benefit from these medications is far greater than the number who abuse these medications, but doctors cannot really know which category a given patient falls into.

  • SarahW

    Indeed, anyone who is a serious abuser and ends up a non-funcitonal addict deserves what he gets, which is misery and ruin, or worse.
    And I am unconvinced that harms resulting from abuse of drugs is in any way diminished by current efforts at gatekeeping and criminal punishment. Not that there is no harn, just that efforts to control do more harm than good and sentence people to a life of unecessary agony.

    • ninguem

      I spend a significant amount of time getting drug-dependent patients OFF opiates, at their request.

      I have many patients who developed addiction after a short course of opiates for fairly trivial pain problems, the sprained ankles, the dental work, etc.

      Anyone who says that never happens is not paying attention.

      • SarahW

        Did they become non-functional addicts? NO.They became dependent on a medication. When it began to affect their daily funcitoning in a negative way, they turned or returned to you for assistance in ending it.

        Peak and valley pain pills (too much then too little) help create this situation, as much as any feared “loadie” syndrome. Recreational drug users get their high any way possible.

        • ninguem

          Both types come to the office.

          Pain, pain treatment, and recreational addiction overlap.

          The only thing they have in common is if they want to get off the drugs…….no matter how they got on in the first place,…….they come to the office.

          • http://www.womeninpainawareness.ning.com carol

            recreational addiction does not overlap with pain treatment. (unless the patient is an addict already or has the propensity.) Again most pain pts do not become addicted. They do not take it for a ‘high’, they do not crave it, they do not seek the meds out in lieu of other activities (if in fact they are able to engage in other activities. Their bodies may become dependent. As long as doctors, the media, and people do not understand the difference we, as pain patinets, will continue to be victimized by this ‘war on drugs”.
            There have been stories of people who take insulin to lose weight. They get it illegally. Do you therefore lump in all diabetics with those who misuse the drug?

          • stitch

            @ Carol: like it or not, there is overlap between dependence and abuse, even if it is not “recreational.” And those of us who have been in practice for long enough have seen plenty of it. Some of us even still get burned although we keep trying to give people the benefit of the doubt.

            And insulin makes you gain weight, not lose it. Just sayin’…

          • http://www.womeninpainawareness.ning.com carol

            insulin is abused and in fact based on a lot of what is said here should be equally prohibited and monitored. “Insulin has been a prescription only medicine in the United Kingdom since 1998, and its use is prohibited, in non-diabetic
            athletes, by the International Olympic Committee.6 However,there is little to prevent diabetics giving or selling their insulinto athletes and body builders.”
            .http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724679/pdf/v037p00356.pdf
            “The reason insulin, and many other drugs, imho, require prescriptions is not that the potential for abuse is so high (though it is there: think body builders), but more that the potential for misuse is high.” http://www.diabetesforums.com/forum/diabetes/18395-why-isnt-all-insulin.html
            As for the patients who have been on opiods for “trivial” pain the docs prescribing are the culprits. That is part of the problem, give them when and for whom they are needed, when prescribed as though it is aspirin you do have overprescribing . I would also assume the word gets out for those wanting the drugs for drug sake. “Hey, go to Doc so and so, say you sprained your ankle and he will give you a narcotic.

          • Monica

            @carol, I appreciate that you took the time to find that article, but I hope you realize that it actually supported what stitch was saying. The article was about bodybuilders using insulin to GAIN muscle mass (and, therefore, weight) and it stated that insulin abuse is not believed to be terribly common.

  • buzzkillersmith

    The medical profession has not yet come up with an adequate solution to the problem of chronic pain management. “Experts” in this area are basically winging it. Their opinions are all over the map.
    Any doctor who wades into this bog is either a fool or a saint. Good luck, Dr. Pullen.

  • http://blog.myphysicaltherapyspace.com/ Selena Horner

    I feel quite lucky that I am not a physician. Physical therapists don’t have the same issues as physicians when it comes to managing patients with chronic pain.

    To attempt to adequately attempt to manage chronic pain, one has to first realize there is no magic bullet.

    In case you were interested in the current science of pain, you’ll really be interested in Lorimer Moseley’s recently shared article on the science of pain. You can find it here: http://tinyurl.com/3g6832s

  • http://drpullen.com Ed Pullen

    The diverse comments above all lend credibility to the difficulty of this whole problem. It’s just difficult, no great answers. Obviously finding a diagnosis and cure is great sometimes, but usually just is not going to happen.

  • Smart Doc

    The reality is that doctors who prescribe lots of narcotic pain prescriptions will eventually generate investigation by federal or state authorites.

    And it is not just the Florida pill mills selling vast amounts of Oxycontin (cash only) to phony SSD “patients” down from Kentucky.

  • soloFP

    I have two pain clinics available to me within a 15 mile radius. They staff anesthesiologists who prescribe nsaids, lyrica, and/or neurontin. No narcotics. True back pain is treated with injections, in a series of 3 and various PT/electrical stimulation. Unfortunately, the narcotics are left to the primary care physician to Rx without any guidance from the specialists. My state does have a database of all rxes filled in the state, which is about 2 weeks behind but is good at catching doctor shoppers. It is a lot easier to simply not rx narcotics and not take the risk. There are around a dozen docs in my area known for packed waiting rooms who will rx large doses narcotics, as long as you get monthly visits. They are functioning below the radar for now.

    • http://zenfire.tumblr.com Zenfire

      “Unfortunately, the narcotics are left to the primary care physician to Rx without any guidance from the specialists.”

      Or maybe they’re telling you their guidance is not to use narcotics?

      • Easton, MD

        I think this comment nicely encapsulates the issue from the physician’s perspective. If the specialist, who is supposed to have the greatest knowledge and experience in diagnosing and treating pain, is avoiding chronic opioids, maybe more of us should listen to them.

        • stitch

          Bingo.

          • http://www.womeninpainawareness.ning.com carol

            The fact that you would lump psychiatric disorders in with your tx regimen gives away your apparent prejudices. Just as most pain patinets do not become addicted most do NOT have psychiatric disturbances. You live with chronic intractable pain and you will probably become depressed, to a level of psychiatric disturbance – not necessarily. Funny your regimen is nothing more than what is the ‘optimal’ suggestions for the population at large. I wonder if you truly think fibro is a disease or chronic pain disorder.

          • http://www.womeninpainawareness.ning.com carol

            I can speak to my case only. He wants the GP to continue to prescribe the same meds. His point is he can opffer me nothing else so drving as far as I do to see him and taking the time for him to see me is wasting both our time.

        • stitch

          However, I should add, of course, that one of the reasons the pain specialists don’t deal with chronic narcotics is that the reimbursement is far, far lower than that for procedurizing the patient. Must always keep that in mind.

      • http://www.womeninpainawareness.ning.com carol

        If that were so, would they not refer the patient to the GP with such info in the notes? “It is my considered opinion this patient does (does not) require narcotic medication for his/her condition.”

  • ptfromou

    I see patients with chronic pain quite frequently in my physical therapy clinic. One of the trends that I see in my area, is the physicians prescribe the opiod meds for a few reasons. 1. They dont have the time to complete a thorough exam to determine the cause of pain. 2. They may not know the cause of pain so it is easier to prescribe them. 3. If the patient doesnt get them, they will go to someone else that will prescribe them what they want. A physician that is afraid to lose a patient will prescribe pain meds. As a physical therapist, I hear quite frequently in my examination, that I spent more time listening to them, and actually touched and examaned their pain, not just where it hurts but also other areas that might be the cause of their pain. I have to stay in good communication with my physicians that refer patients to us with chronic pain, but when I have successful results it is all worth it.

    • http://www.womeninpainawareness.ning.com carol

      If they are doctor shopping it is usually not just pain issues. I think that would be one flag for any doc seeing them. Of course they can lie about how many docs thay have seen. But any doctor who takes even a few minutes to really sit down and listen, even if only the 12 that is supposedly now able to be allocated to each patient, they should be good enough clinicians to determine if there is a real issue or not.
      To address another comment made elsewhere in the thread (I am not getting notifications to take me to the specific comments) 30 years ago there was the belief that those who complained of what we now know as fibro, RSD, or some other pain disorders were dismissed with the admonition to take it easy, see a counselor, you don;t have enough to do, you have too much to do etc. It is now accepted that these are real disorders. Would you prefer to go back to the days when anyone complaining of this kind of paiin was patted on the head and offered valium?”

  • http://www.somebodyhealme.com Diana Lee

    I fail to see what the fact that some people abuse pain medications has to do with me or any other legitimate pain patients who has never abused pain meds, never bought them on the street, and always follow my doctors’ guidelines and instructions. Addicts will always find a way to get their drugs, and undertreating legitimate pain patients doesn’t stop them.

    Further, I also believe there is a great need for a whole holistic approach to pain management that incorporates not only medications, but also coping skills that minimize the suffering associated with physical pain.

    • ninguem

      Addicts will lie about everything, including, major trauma, multiple sclerosis, cancer, and HIV.

      I’ve had patients lie about all those conditions, and more, to get drugs.

      On several occasions, I had strong evidence they were selling the drugs for a living.

      The street value of oxycontin is a dollar a milligram on the street; probably more these days. Do the math. Scam a handful of doctors into believing you have chronic pain, and you can make a living as a professional patient.

      Nobody wants to undertreat pain. It’s not easy to tell the difference between the pain patient and the scam artist. Anybody who thinks it is easy, has not practiced medicine.

      Nurse-practitioners can work independently in the Left Coast, and a large section of the rest of the country. Here’s one near Portland, Oregon, where the patients were all taken at face value when they complained of pain. The daily oxycodone dosage reached a thousand mg in some patients. The drug got diverted, and people got killed.

      http://www.oregonlive.com/news/index.ssf/2009/03/complaints_against_vancouver_p.html

      “Caring practitioner”, or a fool?

      • http://www.womeninpainawareness.ning.com carol

        The article stated they had 40 complaints about the ‘clinic’. The state was negligent in not closing it when the problems first surfaced.

        • ninguem

          I don’t suppose there might maybe be just a little fault attached to the nurses who prescribed these massive doses of opiates?

          I do find it of interest, the Nursing Board did very little, apart from restricting the nurse’s Schedule-2 prescribing rights. Actually, I don’t know if that’s the Nursing Board or the DEA. I don’t know if nursing boards anywhere, have the experience in dealing with nurses like this, exercising independent medical judgment, as opposed to carrying out a doctor’s orders or following a medical director’s
          protocol.

          Nevertheless, the clinic is actually “closed”. As in, operating with the same practitioners under a different name. Unknown to me, if they are shoveling out Schedule 3 and Schedule 4 drugs the way they shoveled out Schedule 2 drugs.

          It is left to the real doctors of Southwest Washington and Northwest Oregon to clean up the mess the nurses made with these patients on massive doses of opiates. Those who were actually taking them, that is, as opposed to selling them.

    • Maria

      oh my god, THANK YOU!

    • gzuckier

      Just because criminals use firearms to wound, kill, or intimidate others doesn’t mean we should restrict access to them by law abiding folks. On the other hand, since criminals use drugs to injure themselves, we must restrict access to them by law abiding folks. i hope this is now clear to all.

  • socialworker

    Why don’t you try Suboxone? Helps a lot for fibromyalgia. So does gabapentin. Broaden out.

  • http://www.womeninpainawareness.ning.com carol

    I have had trigeminal neuralgia for over 30 years. Despite objective evidence surgically and meeting the criteria of TN, I still found some doctors who said they did not believe “in the pain.” Thankfully most of my docs were good, listened to me and to my body and brain.
    I am sorry that some here have not made the differentiation between addiction and dependence. Most pain patients do not become addicted. Some may become dependent, a wholly different animal.
    As long as the DEA has taken their losing war on drugs to doctors offices, patients and doctors will continue to be on guard. Sadly, the few bad apples; physicians and ‘patient’ liars, have made it that much harder for us to be able to get docs who can help get our pain under control.
    Thank you.
    Carol Levy
    author A PAINED LIFE, a chronic pain journey

  • Easton, MD

    As noted in the article, there are very few ways to objectively determine or “prove” pain. You have to go on what the patient says.

    Until there is a magic scanner that can provide objective determination, this will be an unsolvable problem.

    In our clinic with 12 FP and IM docs, none will accept a new patient who is on chronic opioids unless they have a pain doc who will continue prescribing these. It doesn’t matter if they are insured, Medicare/caid or uninsured. I don’t prescribe any opioids for more than 2 weeks. If patients need it for longer, they have to go see a pain doc. In this era of increasing scrutiny of prescribing patterns, most docs shut down the opioids, me included. You might be in a lot of pain. But you might also be a drug seeker or seller. I can’t tell the difference, so no opioids for you. If you’re in pain, you’re still going to be in pain. Sorry.

    I still receive the local paper from the small town of my first practice. Every week, I read about former patients being arrested and convicted to prescription drug trafficking.

    • http://www.womeninpainawareness.ning.com carol

      In fact, they do have a test for fibromyalgia and history and physical manifestations that fit the criteria for RSD make that diagnosable. I am saddened everytime I see the commercial for a migraine med and the actress says “These things are for real”. You have auras, photophobia, etc you fit the disgnostic picture. Back pain, and other pains may not have a specific pic but often efforts to control such as injection are a tertiary way, if you will, to ‘prove’ the validity.
      As long as some docs rely on the outdated idea that pain is a subjective complaint pain patients will continue to suffer at the hands of those docs. They will continue to be stigmatized by the medical community, often looked at suspiciously, called malingerers and fakers..
      (My pain doc wants me to have my GP write for my meds, a very low level narcotic. I refuse to do so because as a pained patient I feel a pain doc should be the one to write for me.)
      Thank you.
      Carol Jay Levy, B.A., CH.t
      author A PAINED LIFE, a chronic pain journey
      http://apainedlife.blogspot.com/
      member, cofounder with Linda Misek-Falkoff, PWPI, Persons With Pain International,
      accredited to the U.N. Convention on the Rights of Persons with Disabilities member U.N. NGO group, Persons With Disabilities

  • JustADoc

    So I was not aware there was an objective test for fibromyalgia. So I looked. Didn’t find one on several reputable sites. Several subjective tests. And I know there are some MRI stuides out there that show some findings that are believed to be related to fibro but I am not aware of anyone recommending that for diagnosis as of yet.

    • ninguem

      Fibromyalgia is a syndrome.

      From the Greek, “syndromos” means “runs together”.

      English definition “a number of symptoms occurring together”.

      In medical usage, a “symptom” is what the patient subjectively feels, by definition something another person cannot objectively see or measure. A “sign” is an objective finding, something another person can see or measure.

      We don’t refer to “appendicitis syndrome”.
      We don’t call it “myocardial infarction syndrome”.

      We refer to these conditions by the known pathophysiologic mechanisms of the diseases in question.

      We use the term “fibromyalgia syndrome”, because we do not, in fact, know what causes the problem. Our “objective test” for fibromyalgia, means there is a defined pattern of symptoms and signs, or in this case, lack of signs, to sort these patients into a certain category.

      So we can make sure the doctor in New York and the doctor in Milan or Tokyo are talking about the same problem.

      So when a doctor in London says he has a cure for fibromyalgia, I would like to make sure he’s talking about the same sort of patient, and not talking about someone with polymyalgia rheumatica or gout or some other problem.

      I get this with patients all the time, unfortunately. They are happy to hear I “believe in fibromyalgia”. It’s a tautology, but it’s just referring to accepting that the patient has a certain pattern of symptoms running together, and few if any objective findings, and doesn’t have a whole bunch of other diseases.

      I “believe in fibromyalgia”, but it does not follow that I feel this collection of symptoms and lack of objective findings, should be treated with opiates or potent banzodiazepines and sure as heck not SOMA. It is also not a cannabinoid deficiency.

      Carol’s “pain doc” wants to pass off the opiate therapy to her primary care doctor. Not sure if she realizes how that speaks volumes about opiate treatment for pain, and in fact proves Dr. Pullen’s point.

      • http://www.womeninpainawareness.ning.com carol

        Better example then. We do not know what causes trigeminal neuralgia. There are distinct signs that make the dx. “We use the term “fibromyalgia syndrome”, because we do not, in fact, know what causes the problem. Our “objective test” for fibromyalgia, means there is a defined pattern of symptoms and signs, or in this case, lack of signs, to sort these patients into a certain category.”
        When a patient does not respond to the therapies you suggest (medications) then what do you do – say sorry you are still in such pain but it is not my belief that narcotic meds are appropriate? If so, I hope you say it upfront. Those who are drug seeking will leave you fairly rapidly.
        He wants to pass me off because there is nothing else he can do or offer me and he is aware of that. He told me from the get go “I do not work with pain above the neck and there is nothing to be done for that but medication so as long as you understand that is all I can do for you I am happy to be your doc.” As such, why take up his time with a patient for whom he has no other answer? My GP would write. I am the one who feels a pain doc is more appropriate.

    • http://www.womeninpainawareness.ning.com carol

      This is a ridiculously long address for 2010 article by ACR on diagnostic crtiteria for fibromyalgia

      http://docs.google.com/viewer?a=v&q=cache:Qo6eeCfpJI4J:www.rheumatology.org/practice/clinical/classification/fibromyalgia/2010_Preliminary_Diagnostic_Criteria.pdf+american+college+of+rheumatology+diagnostic+criteria+fibromyalgia&hl=en&gl=us&pid=bl&srcid=ADGEESj74vULV4qzEkTxqz9_UTy0gXyHei5wBdZvI7oSS6ANoYhhkvnip2o9OraPwJFXPLyzIV2ZMNtL_uQKGIhZufz6y9vktra433yo0DbAG6stc606ZLOan9j4wgmL3HEZH4JkScbe&sig=AHIEtbSAaNOgsrVUjYjgz0Kxu7ee5iCmsA&pli=1

      This is 1990 Dx criteria http://www.nfra.net/Diagnost.htm

      Yes still subjective because based on pain response (but then so too is appendicitis for instance where even when dx testing inconclusive they rely on pt report and pain in the correct area) but pt has to be very knowledgable to know at which points they need to say “ouch” to meet the criteria.

      • ninguem

        sigh………the ACR criteria, in the end, puts the patient into a category. As I just got through writing, it means the patient has a certain collection of subjective symptoms, and lacks a whole bunch of objective findings. The mechanism of the disease is still unknown.

        It is not just mental masturbation, by having specific criteria, researchers can make sure they are talking about the same thing, when describing patients from different parts of the world. But in the end, there are no objective findings to demonstrate a mechanism of disease. Surely there’s something underlying all this, we just don’t know what it is yet.

        Appendicitis is subjective? That’s a new one. I guess the patient has to be knowledgeable enough to run up the white count and fill the appendix with pus as well.

        Sometimes the diagnosis is not clear-cut, the patient might have appendicitis, or may have a Meckel’s or PID or a kidney stone. So what?

      • http://zenfire.tumblr.com Zenfire

        Treatment for fibro is exercise, weight loss, good sleep hygiene and optimal management of psychiatric disorders. Most doctors don’t mind prescribing that in large doses with infinite refills.

        • ninguem

          What Zenfire said.

          One of the reasons for being careful with establishing firm criteria for the syndrome, is to compare notes among practitioners worldwide.

          What they find everywhere, is treating fibromyalgia with potent opiates, benzodiazepines, and major tranquilizers like SOMA, will not help, and will likely make things worse.

        • stitch

          And studies have shown that very well, that the best treatments for fibromyalgia are CBT and graded exercise.

          However, you have a large subset of patients, not to mention some activist groups, who reject that because they argue that is saying it’s all in their heads (hello? that’s where pain is perceived) and that’s just telling them they are “crazy,” and don’t have a “real” problem.

          Not to mention the ongoing search for the magic pill.

  • SarahW

    “But you might also be a drug seeker or seller. I can’t tell the difference, so no opioids for you.”

    Priorities. You have wrong ones.

    • Easton, MD

      Sarah,

      You’re right. I do have priorities. Some of them include maintaining my medical license, being able to make a living and provide for my family, staying off the Fed’s radar, avoiding prison time, and not contributing to the massive increase of opioid diversion rampant in our country. Prescribing chronic opioids to patients with difficult-to-verify diagnoses increases my risk of all of those problems I hope to avoid.

      Do you really think that there is so much more pain today than there was 30 years ago when opioid prescribing rates were very low? I don’t. I do think that many doctors hand out opioids like candy, and this is contributing to the addiction, diversion and overdose deaths.

      I realize that doctors have a broad range of opinions regarding opioids from chronic, non-malignant pain. I happen to be one who feels that opioids are rarely appropriate in this situation, despite the aggressive lobbying by Purdue Pharma and others during the 90s.

      I have had patients who have died from taking their friend’s Oxycontin and methadone. I try very hard to not contribute to my patients’ accidental deaths. I don’t want bottles of Lortab being sold out there with my name on the prescription bottle.

      • ninguem

        I always find it hard to figure out how we’re doing such a horrible job with pain management when the overwhelming majority of opiates prescribed worldwide are consumed here in the USA.

        In the eyes of many who write here, the quality of pain management is directly proportional to the mass of opiate shoveled out. By that criteria, the USA should be heaven compared to the rest of the world.

      • stitch

        Absolutely.

        I tell my patients all the time that it is not my job to be their drug dealer. And I’m getting increasingly likely to say that.

        This problem exists across racial and income lines. I’ve worked in a community health center, in hospital based clinics, and in posh suburbs. It really doesn’t matter, I’ve seen patients in all of these locations. And as I said above, I still get burned.

        Allopathic medicine does a poor job of dealing with chronic pain at all levels, and I say that to people all the time.

      • SarahW

        “I have had patients who have died from taking their friend’s Oxycontin and methadone.”

        I think people who want to abuse drugs essentially get what they deserve in terms of health risk and personal ruin. They should not be your priority, in my view – your job is to manage your patient’s risk, not that of other people. Your duty is to the individual, and not people who might abuse medicine not prescribed for a medical condition but to play with.

        • SarahW

          “I have had patients who have died from taking their friend’s Oxycontin and methadone.”

          I’ll add an analogy – it’s like saying you won’t sell a car to someone who needs transportation, because some 16 year old or irresponsible adult friend will take it drag-racing.

          And a car-salesman, unlike you, has no duty to meet the needs of a potential client. YOU DO.

        • Easton, MD

          Well, in the utopia that you describe, that would be true. But here in America, plaintiff’s attorneys take a different view. If I prescribed 20 Lortab to a patient for a broken ankle, but they also were abusing methadone, soma, and Xanax and they overdose and die, courts have held that I may still have some partial liability. They could argue that I should have done a drug screen, and should have called the patient at home the next day, etc.

          If a patient doesn’t follow my instructions on the prescription bottle, and takes 6 Methadone in one day and then doesn’t wake up, it’s still quite likely that I’ll get sued. Even if I ultimately prevail, it takes a lot of time, attorneys fees and emotional burden.

          “Your duty is to the individual, and not people who might abuse medicine not prescribed for a medical condition but to play with.”

          Again, this is easier said than done. It’s very difficult to distinguish between the legitimate pain patient and the one who is determined to fool you.

          So, I just don’t do it.

      • tim

        actually doc, today there is more pain than 30 years ago. With growing obesity rates arthritis is growing out of control. If you believe bone on bone in the knee does not induce a life full of pain, i think you need to go back to med school…

        tim

        • stitch

          So, is the answer to that more addictive, potentially dangerous pain meds, or proper diet, physical therapy, and exercise? How ’bout gettting out from in front of the tv?

  • Maria

    30 years ago, being prescribed opiates never seemed to be an issue. Now, and this is not an exaggeration, it would be easier for me to buy opiates on the street than get a prescription. I am not a doctor, however I am, reluctantly, a patient. I have had RA since my high school days in the early 80′s, altho’ recently I’ve been told it’s actually lupus. As RA goes, it’s been relatively mild but it’s also been 30 years. I have had three orthopedic surgeries within the last 18 mos. Is anyone questioning the fact that I live in daily pain? I don’t think so. I have no history of substance abuse, I don’t even drink. Yet recently, when my PCP advised me to go to a pain management center, (because SHE is nervous about continuing my vicodin scrip), no less than FIVE pain management centers, (I live in Northern NJ, so luckily have access to a lot of good healthcare options) have declined to take me as a patient. FIVE! Every single one said that they ‘focus more on the spine’ and injections and I wouldn’t be a good fit. Well, although an MRI once told my doctor that I had broken a vertebrae in the past, (at this point I also have osteoporosis) my back pain is negligible. I have provided these places with voluminous documentation, filled out questionnaires of several pages, (one of which, when it was returned to me, had my answers that I am divorced and smoke highlighted…wtf?) yet i have not even gotten an appointment! My therapist has even offered to vouch for me, but that offer was declined. And, because I took 800 ibuprofen for over 25 yrs, my stomach can no longer tolerate ANY NSAIDs. Right now vicodin is the only thing that works. I don’t like it but I also like to work and have a life…and why shouldn’t I? This is a simple solution that contains my pain levels enough for me to continue to work and enjoy life at least somewhat, but apparently this is not something I will be allowed to do. I have about two days left on my current prescription. I guess what’s going to happen is I’ll detox cold turkey, spend a few uncomfortable days and then try to continue on in a miserable ball of pain. Why? Because some people abuse drugs. I blame Nancy Reagan. Just say no, indeed.

    • Zenfire

      Chronic narcotics for RA or Lupus? No. But what would I know, I’m only a rheumatologist.

  • socialworker

    @ Maria, so sorry for the position you have been placed in. I was once in a similar spot, and as I posted earlier, I have FMS that was helped by Suboxone, gabapentin and a really good pain clinic doctor who was willing to try out different theories and tried Suboxone. I was in so much pain at the time I could not function, and couldn’t work. I still have pain, but I did go back to work for awhile. Look for someone who prescribes Suboxone for addicts and see if they will prescribe it for you. You shouldn’t have to go to someone like that because you aren’t addicted, but if you can’t find anyone else…Another shot to try is Methadone, cheaper but more addicting than Suboxone, but also used to treat pain. Go to a support group in town and see if anyone can recommend a specialist that they use that will prescribe the meds you need. Continue to look for pain clinics in other places, maybe even a drive away, because once you get on a treatment plan, you don’t usually go see them more than once every 2 or 3 months, unless you are having treatments other than the ones I mentioned. Finally, you might want to go see a counselor who has experience in working with chronic pain issues. They may be able to help you learn how to cope with your pain better, and help to decrease the fear and anxiety associated with having lots of pain, which reduces pain levels themselves. No, you aren’t “crazy”, but it never hurts for anyone to talk to someone who can provide assistance. BTW, it is almost impossible to abuse Suboxone, and it doesn’t give a euphoric affect. So maybe some of you reluctant pain doctors out there should take a look at it too. You would be prescribing it off-label, and you would NOT have to have a Federal license to prescribe it, as long as you were prescribing it off-label for pain, according to my pain clinic staff.

    • stitch

      You cannot prescribe Suboxone without a specific license. It will not be distributed. You have to have a special DEA number for it.

      Methadone can be prescribed for pain in a regular office by anyone who has a regular DEA number but it has to be given in divided doses. It does not give euphoria and is difficult to abuse. It is also much cheaper than other narcotics. There are few patients, in my experience, who find it acceptable.

    • ninguem

      “…..30 years ago, being prescribed opiates never seemed to be an issue……”

      That is just absolute nonsense.

      It was an issue 30 years ago, and it was a BIG issue.

      But what do I know, I was just practicing medicine as University faculty 30 years ago, with a pain fellowship and boards, giving lectures about how we underdosed opiates in those days.

      And to my regret, speaking and writing about underdosing opiates has left people with the impression that the drug is like Holy Water From Rome, and it gets shoveled out in megadoses, and they show up in the ER with overdoses, and in the morgue.

      • stitch

        We were underdosing it for cancer, clearly. That’s where the data lies with regard to appropriate dosing of narcotics, and it’s where all the research was done. It’s still where the data is. There is no good data on the use of chronic narcotics for non-neoplastic pain. Not even for clear problems like severe arthritis or similar issues.

        Let’s not forget the oh-so-lovely Joint Commission and their mandate that all patients must be asked about pain and telling patients that they have a “right” to pain relief. Like it’s in the constitution or something. Add in patient “satisfaction” surveys and the problems of patients going from ED to ED getting multiple scripts (can’t tell you how many times I’ve done a claims search and been amazed at the frequency of ED visits by some of these patients) because the ED is not allowed to turn patients away.

        It’s all gotten a bit ridiculous. But you already knew that.

  • Meg Bressette

    I read this article hoping to read something new but instead read the same old prejudices against pain management for chronic pain patients.
    I had the same Dr for about 20 years who was my physician when a co-worker broke my neck & assaulted me. I was diagnosed years later with fibromyalgia but controlled that by yoga, tai chi, meditation and even though it remains in my file I consider it to be not a problem any longer. Then my cervical vertabrae collapsed from the previous injury, herniating two discs with nerve entrapment & spinal cord compression and the pain began for me. I saw a pain doctor who tried cortisone shots – one on a Friday afternoon that left me screaming in pain all weekend and when I went in for follow-up with him he informed me that he was going to do another injection even though I had such a bad reaction to the first one. I did antiseizure medications and had life threatening reactions that put me in the hospital. So I called my primary who helped me find a physiatrist who worked with me for a year. We did physical therapy, TENS, a nerve study and finally found a pain regimen at the lowest doseage possible that keeps my pain at about a 4 every day. I was evaluated by surgeons at some of the top hospitals in the country who assured me that if they operated on my neck I would be paralyzed so there is no surgical option.

    Now my Dr has left practice and I am trying to find a new Dr to see me. Most of them see my file, make an assumption about me and then tell me to go cold turkey off of the pain meds – all because they lack the one thing that is vital – CONTEXT. I am not a drug seeking hypochondriac or as someone said above “professional patient”. I have had Drs demand, not suggest, that I stop the pain meds. One said “Why wouldn’t you have surgery if they could fix your neck?” but didn’t listen to me when I told him that I had been evaluated extensively and surgery is not an option. He insisted that I make an appointment with a surgeon.

    While I acknowledge that people abuse pain medications I also acknowledge that Doctors come into these interactions with biases and pre-determined opinions about chronic pain treatment – neither of these help me as the patient. If I didn’t have to take these medications I wouldn’t but that’s not the way it is for me. For now I continue to try to find a primary doctor and miss the one that knew me.

  • http://www.womeninpainawareness.ning.com carol

    Many states already have monitoring programs in place:

    As of July 2010, 34 states have operational PDMPs that have the capacity to receive and distribute controlled substance prescription information to authorized users. States with operational programs include:

    Alabama, Arizona, California, Colorado, Connecticut, Hawaii, Idaho, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Nevada, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, West Virginia, and Wyoming.

    Seven states (Alaska, Florida, Kansas, New Jersey, Oregon, South Dakota and Wisconsin) and one U.S. territory (Guam) have enacted legislation to establish a PDMP, but are not fully operational.

    *Washington State’s PDMP was operational but has been suspended due to fiscal constraints.

    Delaware has legislation pending to establish a PDMP.

    http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm#4

    Fear of the law, if you are practicing within the boundaries of the law and what a patient’s needs are should not be a problem. Big Brother is already looking over your (and the patient’s) shoulder.

  • ninguem

    Here’s a few cases where the prosecuting attorneys apparently did not hear your sage advice.

    http://www.painandthelaw.org/aslme_content/26-4c/alpers.pdf

  • ninguem

    And a few more, some of the stories overlap.
    http://www.amazon.com/No-Good-Deed-Medicine-Accusations/dp/006172176X

    • http://www.womeninpainawareness.ning.com carol

      Palliative end of life care is not equivalent to treating those with chronic intractable (non terminal) pain.
      People may be ‘snowed” at end of life care. You cannot do the same with someone who is living with chronic pain. One would hope the physician would see his job as being helping the patient get to a point where the pain is tolerable, maybe even get to the point where, if they are disabled by the pain, able to work again. (For some just enabling them to get out of bed or tie their shoes is a major accomplishment.).

      • stitch

        No one here is saying that adequate treatment of pain is not a worthy goal. What most of the practitioners here are saying is that there needs to be an alternative to potentially dangerous, addictive medications that have a high abuse and diversion potential.
        Studies continue to show that the role for narcotics in chronic non-malignancy pain is limited.
        We need better solutions to this problem, and those solutions need to be multi-disciplinary.

      • ninguem

        Geez carol……sigh.

        No kidding, palliative care is not the same as benign pain. So here are doctors getting prosecuted for providing PALLIATIVE CARE ON TERMINAL PATIENTS. That’s the kind of treatment where no one argues, give them what they need to stay comfortable, you don’t have much to lose.

        And the doctors STILL GET PROSECUTED.

        “……Fear of the law, if you are practicing within the boundaries of the law and what a patient’s needs are should not be a problem……”

        Carol, I can’t put it any plainer. You don’t know what you’re talking about. Doctors have been prosecuted AND PUT IN JAIL for providing palliative care that should not have been controversial in the least. I’ve documented it extensively.

        If you don’t think doctors get prosecuted for the more controversial matters (chronic benign pain), when it’s obvious that they get prosecuted for the non-controversial stuff……you’re living in a dream world.

        But what do I know, I just have boards in Pain Medicine and have seen these things first-hand.

      • ninguem

        OK, you just got through saying:
        “Fear of the law, if you are practicing within the boundaries of the law and what a patient’s needs are should not be a problem.”

        I’ve just given multiple examples of doctors who did precisely that, and DID get in trouble with the law.

        You then point out the obvious, that palliative care at the end of life and treatment of benign chronic pain are two different things.

        Yes. Palliative care at the end of life is not very controversial. Give the patient whatever is needed for comfort. Yet the doctors STILL got in trouble with the law, and in some cases JAILED.

        You’re making my point, the doctors DO run the risk of running afoul of the law, even when the treatment is NOT controversial, such as end of life care, let alone when it IS controversial, like chronic benign pain.

        • http://www.womeninpainawareness.ning.com carol

          My point was the clicks you gave were articles on palliative care, NOT chronic docs and patients. End of life care is controversial. Too many people still believe you should do everything no matter what the patient has requested, if they have a living will, or how much pain/despair the death process will cause.

  • ninguem

    Here’s a 60 minutes story. Listen to the prosecuting attorney, a nurse with a law degree, the worst of both worlds. Listen to her tell Ed Bradley that old people don’t feel pain like younger adults, so the treating doctor must have been playing Jack Kevorkian.

    http://www.weitzelcharts.com/Sixty_minutes.mov

    • http://www.womeninpainawareness.ning.com carol

      This is why living wills are so important. We cannot let nurses and doctors inflict their political, religious beliefs on patients as it seems happened in this case.

  • http://www.facebook.com/thickisbetterxo Jessica Lynch

    So for the people out there that really ARE in pain, their unable to get pain relief because of the abusers,misusers and drug addicts! So pathetic.

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