Monday, October 15, 2007

Narcotics and Appropriate Pain Management

File these stories (story 1 and story 2) under A for Ambivalence; that is the medical community's schizophrenic ambivalence regarding pain management. Medscape is running two typically contradictory stories on this issue at the same time.

The first one describes a review article on noncancer pain management suggesting the broader use of narcotics (opiods) in this setting. Most primary care providers have become increasingly comfortable using such drugs for many chronic pain conditions (back pain, arthritis, chronic pelvic pain, fibromyalgia, and many others). For them, this article is probably old news.

The second story was also reported by Medscape. It is about a survey of members of state medical boards indicating that state and federal regulators may be increasing the number of prosecutions for prescribing these same drugs.

Great. As the appropriate indications for narcotics are expanding, more doctors may be going to jail for offering such progressive care. Given the modern recognition of pain as the "fifth vital sign" not to mention the increasing medical liability assumed by not controlling it, prosecuting more doctors doesn't seem the way to go.

Medical boards and regulators need to catch up with medical science.


Blogger ERMurse said...

Treating Pain is important but does not necessarily require opiods. Making the pain scale (1-10 scale) the fifth Vital Sign was a mistake and not supported by any evidence. This along with Patient Satisfactions Scores being the flavor of the day has lead to a doubling of the use of Narcs in the past few years. I feel the line has been crossed from concern for treating pain to reckless practice in some cases both for the patient and the public. When I think of the number of people driving on the road who are on high opiods it concerns me.

I have experienced back pain, had back surgery, steroid injections, and physicial therapy. I also work in a busy ER and see many patients with simular conditions. My personal experience is that opiods are the least effective method of treating pain in the long run with the most complications and they do nothing to address the underlying problem. I found exercise the most effective. In our instant gradification world that is a hard sell. Most people want the pills.

October 15, 2007 10:03 AM  
Blogger The Medicine Man said...

Dear ER Nurse,

Strictly speaking, you're quite correct that narcotics can easily be overused and over-prescribed. However, there is an increasing body of literature suggesting that they have a role in certain chronic, noncancer settings. There have been studies that demonstrate increased patient satisfaction and improved ADL's with narcotics compared to acetaminophen or NSAIDS.

Your personal experience is not uncommon however it is not universal.


October 15, 2007 12:08 PM  
Blogger Dino William Ramzi said...

I was taught by Dr. Melzack himself and still consider that he was wrong in attempting to expand indications for chronic opioid use.

As most people who are concerned about their own area of research and their personal agenda (be it breast cancer, bowel disease, or pain control), no matter how worthy, he does not consider the implications on all the other parts of the complex social system in which we all live and work and prescribe.

The proper role for abusable medications in chronic pain is drug of last resort to be used only begrudgingly when you have no choice.

October 15, 2007 1:29 PM  
Anonymous Anonymous said...

I think the issue of narcotics for pain use is not black and white. I have had full body RSD for 5yrs. I am a white, 34 year old female who, when diagnosed was told by first of many dr's, my first, Physical Medicine Dr. that she already thought my right arm was "already dead". However, if you know anything at all about RSD, you will know that the bones may die but the pain lingers on. Fortunately, the bone marrow was still receiving blood, and have been on a long road to recovery since then. I have worked incredibly hard to get myself back to LA from the Bay Area to continue on with the work I was doing prior to being injured.

As a chronic pain patient, I initially scoffed at the McGill Pain Scale, thinking how can I possibly narrow down the scope and range of my pain into a number? The more surgeries, physical therapy and non-opiod medications I tried- the worse I got. I am a full believer in multi-modal healing treatment plans. I have done everything from stellate ganglian blocks, to spinal cord epidurals, botox injections in my back, facet joint blocks and the list goes on. I came to embrace the McGill Pain Scale as a way to try to help those who had no comprehension of the pain I was in. Wether or not it is arbitrary, false, etc- it can help when trying to explain to others just how much pain you are in. And of course, it is obvious- pain is relative. We experience it, process it and deal with it in our own personal ways. But, it can be of great benefit for those of us trying to explain our pain to those who have no concept.

I envy those who benefit from these procedures. I used to envy cancer patients, parapalygics and others who had serious, pain riddling diseases, and illnessess that left them like me in a wheelchair unable to use my limbs- but who were recognized and "valued" by societal standards for needing medication, and even having a "valid medical condition."

I was a part of a MRI study at stanford that shows people who suffer chronic pain for a certain amount of time have 6 extra pain receptor sites in the brain. I know from my experience, that when this occurs EVERYTHING becomes painful. It affects not only the person with the pain, but their family, caregivers, friends, lovers, spouses, etc. I was ostracized by some people for this notion of "being weak and taking narcotics", and others just for not being the "old me, highly organized, hard working, nurturing and a problem solver."
Dealing with the loss of family, friends and having essentially no support system was not easy to deal with. Not to mention losing the ability to use my hands and feet, suffered from causalgia dystonia, hypoallodinia and the list goes on for miles.

I resisted the narcotics because of the stigmas attached. I had been a dancer for 25 years, and worked in the medical field running a family practice which I also helped create, manage and run and preventative health clinic as a part of it. I was able to work for a while with the initial onset. But, as it was becoming more and more apparent that the invasive procedures like the nerve blocks, facet blocks, non-opiod medications were not only NOT helping but after I had the spinal cord epidurals, along with a multitude of blocks and other procedures- I ended up in a wheelchair, wearing diapers, unable to dress or bathe myself. The dystonia began to disappear, but the future was grim.

When I finally accepted the fact that opiod based medications were the one thing that helped, and those that felt I was "high" and abusing them were not friends nor could they ever comprehend living with 6 extra pain receptor sites- that I had to make a choice to embrace the medications. I also made a choice to begin to look at the situation as treatable, and not a life sentence. It was then that things changed. I began to gain strength by crawling up stairs, I changed the sensitivities I had by being in dark quiet spaces and began to be very careful with whom I surrounded myself with.

The stigmas that go along with taking narcotics are far reaching. They affect the Dr's who hesitate to treat patients who may benefit from the medications, thus affecting the patients who would be able to function better with the medications. It creates a horrible catch 22 situation for everyone.

As for "all the people high on narcotics driving around", well, I have never felt "high" from my medications. They help quench the pain from having 6 extra pain receptor sites. The minute I do feel high would be a day I'd welcome with a party- a party to mark the end of needing my medications.

And responsibility to adapt to medications before driving is certainly important. It is great you were able to push through your pain, work it out, had surgeries that worked. I can now tolerate physical therapy, walk without even a cane, moved back to LA to being pursuing an active lifestyle again.

Certainly, there are those Dr's and patients who will abuse prescriptions, but there are those who do not. And those that lump us all together only further create a schism, a lack of understanding and move us further away from research into learning how to use narcotics as a tool to get to the point, for those who are not as fortunate as you, to be able to tolerate and benefit from forms of treatments that will ultimately lead them to a narcotic free life. And those who take narcotics, know the side effects are not pleasant, and it tends to be quite easy to differentiate between a patient who is an addict, getting high from these meds- than a patient whose life has improved because of them.

It surprises me to hear this "throw some dirt on it, get back in there and suck it up attitude" from a person who perhaps no problem with other medications like synthroid. Clearly, the neurological aspects to chronic pain are complicated, but essentially they fill a gap that the body cannot. Isn't that the wonder of modern medicine?

Ultimately, my story goes further and deeper. I would just like to say- I do have big issues with people who use narcotics recreationally, because it only further works against those who need the medication to live a functional life. And yes, it is certainly a personal case to case basis to define this.

I have been affected by the push and pull of patients pain bill of rights, and the increase in prosecution of pain medicine prescribers. Having worked in the medical field for many years as well, I have seen both sides prior to having chronic pain. I think ultimately, compassion, research, and keeping an open mind by not putting all narcotic prescribers and patients in one catagory is the most important thing to do.

June 19, 2008 12:19 PM  
Anonymous Geckotatgirl said...

I just found this page randomly when searching for "pain management los angeles" and read through the comments with interest. While I understand where ERNurse is coming from and don't necessarily disagree, those with chronic pain know the catch-22 of exercise vs. medication (i.e., "I know I'll feel better if I exercise but I hurt so much that I can't bear to start exercising."). Breaking out of that takes willpower above what some of us possess. Using narcotics appropriately to treat pain may enable the patient to do the exercise needed to feel better and then again, someone may NEVER erase chronic pain solely by exercising (although that's no reason not to exercise; it's one of many tools in the patient's arsenal). I was very interested in Anonymous's post because it said exactly what I'd love to say to the naysayers, medical professionals, friends, and family who think I'm "taking the easy way out" by taking pain medication on a daily basis. Interestingly, when I got to the bottom of the post I saw that it was posted in the middle of the day on my 40th birthday. Providence? Maybe. My biggest problem is that I don't really like my pain doctor but when I search for a new one online, I get page after page of pain "clinics" of dubious reputation. My current pain doctor is with a renowned sports medicine clinic. He is among the best in his field but I don't like his personality. I feel like my visits are just to get more medication without talking about other options. I've tried acupuncture with some success as well as cognitive therapy which I found very helpful. These other actions I took in conjunction with narcotic pain medication because nothing seems to work on its own. I, too, have never felt "high" from my meds but I know that FEELING high and BEING high may be two different things. I know that I can drive and behave normally while I take it appropriately and as the stay-at-home mother of two small children, I'd be unable to care for them without taking something to ease the pain. My biggest concern is that my children will see me taking my meds and think everything can be solved with a pill. That - and having a teenager in the house with narcotics - is something I will have to rethink as they get older and understand more about my condition. A lot of conversations will be taking place in the future. As for the pain scale... well, I think it's a joke, personally. The pain I feel as a 6 or 7, someone else might describe as a 10. Many times I've considered going to the ER for additional help but I'm afraid of looking like an addict "shopping" for more meds. My ultimate goal is to be free of meds completely one day. That day seems far off since I'm still in the state of trying to stave off long-acting meds as long as I can. It's nice to know I'm not alone in this. I do recommend cognitive therapy highly; it's nice to have someone to talk to and cry to without burdening family and friends who may be sick of hearing about your problems. Now, if I could find a good pain doc in Los Angeles, I'd be set!

October 07, 2009 9:00 AM  
Blogger Jena said...

As someone, at 57, who has 3 spinal fractures, osteopina, advanced scoliosis, and fibermyalgia, I need the medication to start the exercises and keep going. Pilates, yoga, strength training, and diet have helped me. I was losing the ability to sleep which further worsened the pain.
I take opiates when needed and muscle relaxants when needed. I am living an improved quality of life, came out of my depression and couldn't care less about people judging me for being "an addict". Let some of the righteous politicians and "health care" practioners try it and see how quickly they change their attitude. Compassion, wisdom and empathy towards each other comes through with communication. Some people feel pain more readily and its intensity, so meds do help, no question about it. God bless those doctors who understand and Light to those who don't.

January 17, 2010 4:08 PM  
Anonymous pain management emr said...

Yeah! I agree with you there, "more doctors may be going to jail for offering such progressive care" I think it can be consider as a drug abuse. I hope that they can do something about this issue. Thanks for sharing.


April 11, 2011 1:22 AM  
Anonymous pain management emr said...

Nice topic! It is really need to determine an appropriate pain management in a certain situation. Anyway, thanks for sharing this post. I enjoyed reading it.


April 12, 2011 6:43 PM  
Anonymous Anonymous said...

I am a physician and it is my duty and OBLIGATION to reduce the suffering of my patient. Yes I take precautions, but I do NOT deny pain medications when they are indicated and find that in most cases the patient doesn't want to be high dose opioids. Pain Management shouldn't be cutting edge science and physicians are just that physicians/healers; we are NOT DEA or LAPD and that level of mistrust is insidious and almost immediately harms the doctor patient relationship.

August 17, 2011 2:28 PM  

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