Wednesday, February 28, 2007

Pain Management Dilemma

The Washington Post came out with an article on Tuesday with the attention grabbing headline, "Doctors Warned About Common Drugs For Pain: NSAIDS Tied To Risk Of Heart Attack And Stroke." The American Heart Association came out with a statement discouraging use of Cox-2 inhibitors because of it's association with heart attacks and stroke.
"In the past, many physicians would prescribe the Cox-2 drugs first," said Elliott Antman, a professor at Harvard Medical School who led a group of experts assembled by the heart association to study the issue. "We are specifically recommending that they should be used as a last resort."

"This is a very firm statement we are making," he added. "It is our belief, hope and desire that physicians will take our advice, and by doing so it is our belief and hope that we will reduce the number of patients who suffer heart attacks and strokes."
Now, I have no problem with this. My patients have been scared off from these drugs with all the press coverage that has been surrounding these drugs, that the mere mention of these drugs during an office appointment sends the patient running away.

Here's where I start to have a problem with the AHA statement....
Patients should be treated first with nonmedicinal measures such as physical therapy, hot or cold packs, exercise, weight loss, and orthotics before doctors even consider medication, said the AHA scientific statement published in the journal Circulation.

Patients who get no relief after those measures have been exhausted can be considered for drug therapy, but doctors should try drugs only in a certain order, the statement said:

"In general, the least risky medication should be tried first, with escalation only if the first medication is ineffective. In practice, this usually means starting with acetaminophen or aspirin at the lowest efficacious dose, especially for short-term needs."

While most patients are likely to be helped by those drugs, a smaller number may need to try a drug such as naproxen. Patients who require additional help should be given other nonprescription painkillers such as ibuprofen, and only after that option has been exhausted should physicians consider Cox-2 inhibitors, Antman said in an interview.
I can tell you as a primary care physician, most of our patients already do the non medication therapies even before seeing me. In addition, they have already tried a number of over the counter antiinflamatory therapies. When they come to me, they are usually looking for the next step up in therapy. Then, when I introduce the idea of the Cox-2 inhibitor, they balk. So, now what? Hold that thought....

In doing more research on this topic, I ran into an article entitled, "The Poor Management of Pain." It talks about how physicians do a poor job at managing chronic pain, especially with the reluctance in using opioid/narcotic medicines.
It is seemingly a no-win situation. On the one hand, the more you treat pain with opioids, the more likely you will be investigated by state or federal authorities. But, on the other hand, the less you treat pain with opioids, the greater your chances of being sued for civil damages on the grounds of undertreatment.

“Lawyers are lining up right now...looking for cases of poor pain management,” according to remarks given by Bill McCarberg, MD, director of the Chronic Pain Management Program at Kaiser Permanente in San Diego and an assistant clinical professor at the University of California, San Diego, who also serves on the board of the American Pain Society. “Whenever you encounter litigation against doctors for pain management, it is never because...we do not allow the patient to get a muscle relaxant...It is always about opioid management. We get sued because we’re not using opioids.”
So, on a daily basis, I'm constantly challenged on how to adequately treat my patient's pain. On the one hand, there are antiinflamatory medications which have the dangers of heart attack and stroke - News Headline: Doctors Warned About Common Drugs For Pain. On the other hand, there is the use of narcotic pain mediciations which have the dangers of addiction and tolerance - News Headline: Doctors Do A Poor Job At Pain Management. I apologize for the whining, but sometimes all this stuff really makes my head spin.


difficultpt said...

. . . sounds painful.

Dreaming again said...

if it's any consolation doc, for those of us who understand the medical issues ...and libel issues ...and moral issues ...and live with chronic pain ...

it makes our heads spin too.

We're in this together.

Take the anti inflammatories so the joints don't deteriorate more, take the pain killers so that you can function to a degree ...however ...the more you take ... the less they will work ...and the sooner they will loose their effectiveness ... and cause need for more or different ...

and then what happens when you have surgery or an injury and you're already on the pain remedy for chronic pain that's used to handle acute pain? only there isn't any place to go?

How much pain is too much pain to live with (is an elevated blood pressure from pain levels something that should be tolerated? then you take a blood pressure medicine AND do something for the pain about a compromise ... blood pressure medicine and a little for the pain ...)

It's a team effort doc ..and most of us dealing with it ...understand that you understand. What can we do? We're caught between a crappy legal system and a crappy body system? Neither one wants to cooperate to work right?

SeaSpray said...

Hi Dr. A - thanks for the link. :)

So, does this mean that I-buprofen is bad for a person and if so under what circumstances, generally speaking? 12 years ago I took 1 dose of 600mg ibuprofen every day for a year for significant knee pain. I would take it at the busiest time of day. I did this until I could hardly walk. I was being head strong about it and refused to be seen by a doctor.

Turns out it is one of the most stupid things that i ever did medically because it was a torn meniscus. Sameday surgery and I was as good as new in 2 days!

Sorry,I digressed. I-buprofen is still my drug of choice. It helps me with everything. I prefer that over a percocet any day for a headache. In my case the urologist has said that i-buprofen is not good for the kidneys so I have used it, but sparingly.

I give this to my son and husband when they have headaches. Is tylenol the safer choice regarding strokes etc.? If I am getting a headache - I don't have a choice. percocet or tylenol will allow a bad headache to exacerbate into a mighraine with me. Fortunately they don't happen often.

So, this inquiring mind wants to be clear on the I-buprofen thing. Thanks. :)

Re: suing doctors for poor pain management - give me a break!!! Like you guys don't have enough to be concerned about. I know that there are guidelines for protection - both ways, but I loathe the idea of lawyers lining up like vultures. The litigious mentality is counterproductive for patient and doctor.

LJG aka Pennsylvania Independent said...

This is one reason why I stopped taking all medicine to treat my bipolar disorder.
You hear from the media that alot of anti-depressants can cause suicidal behavior in children and in adults as well.
Paxil, Seroquel, and Geodon were found to cause severe health problems.
This is one reason why I walked on medicine and for the most part psychiatry.
I do not recommend others to do the same. I know that medicine has helped many with many mental illnesses. Some people are in dire need of these medicines.
The other reason why I stopped taking medicine is my insurance will not cover medicines used in psychiatry. I know there are patient assistance programs out there and when I tried applying most recently, because I have insurance the drug companies want to know why my meds are not covered. It just feels that I was given up on because I have had a hard time getting them through other means.
I decided the best thing to do was to end all of my treatment.
I have had some issues with bipolar disorder and not being on meds, but I have overcome the issues I had for the most part.

Lori said...

Thanks for linking up with me, Dr. A. I'm honored to say the least! I love reading your blog.....tons of useful info AND a sense of humor! :)

Ajitbhai said...

Thanks a lot for your comment and adding me on your link list.I am honored indeed !!!

The dilemma you all face when treating pain is very obvious from your post. We have a different picture here.

Patients,including educated and well informed ones are careless in their drug consumption.Less stringent rules and control over chemists lead to easy availability of OTC medicines,even those that should otherwise be under prescription.No control exists over doctors from other systems like homeopathy , ayurveda,etc in using modern medicine.

Patients demand relief from pain.If we cant provide them due to our concern for law and harmful effects,they will get it from the next door chemist.

NSAIDS and Cox 2 inhibitors were very useful for pain and I am fortunate not to have seen any of the serious side effects mentioned and discussed world wide.

You will be horrified to know what all permutations and combinations are available here. Quoting a few, apart from single molecules of diclofenac,acceclofenac,Naprosyn,etc we have various fixed dose popular combinations like
2]Diclo+Para+some muscle relaxant
In place of Diclofenac we can have acceclofenac.
The list will never end......

Andrea said...

Damned if you do, damned if you don't.

Frankly, I think when that first lawsuit came through against a physician for a large award, the medical profession has had a giant bullseye pasted on its back and a great disservice was done to the public.

I try not to pay much attention to media when it comes to medicine, and anything that raises my curiosity and applies to me I just make a point to ask my PCP about it. She doesn't have a reason to spin the story like drug companies giving press releases.

Anonymous said...

Something that I've had to deal with in particular this past year is the saying that the possible benefit of taking the drug I need far outweighs the risks I may encounter from taking it. While no one (I hope) would choose to take unnessesary drugs(pain or otherwise), there are appropriate times to take them. Muddy

N=1 said...

Speaking as a provider and one who has lived with chronic and intensifying pain over years, pain management is a farce. All of it. Providers are suspicious of patients. Patients suffer needlessly, and god help the patient who doesn't respond to the mildest of pharmacologics as a textbook case. I've lived on naproxyn purchased OTC but taken at the highest end of prescrption doses for years, and still my dominant hand is atrophying from an ulnar nerve problem. Surgery isn't an option - heck, seeing anyone isn't an option. I don't have the financial resources to do it, and the outcome wouldn't change. So I watch as my hand function disappears, my pain increases and no end in sight. That doesn't even address the multiple joint pain from osteoarthritis - but you know how nurses break their backs, and are then tossed out by the employer.

I at least know enough about how to manage pain. What about the millions of poor schlubs who don't or can't?

gay CME guy said...

As another member of the group who lives with chronic pain (and works in healthcare), it does make all of our collective heads spin. I've been on opiodes for much longer than I would wish. I have tried eliminating, but I end up going from a 2-3 on the 'pain meter' to a 6-8. I also do a pretty high level of electro stim. THe patient really has to take ownership of the pain, and communicate well with their doc to try and manage it together.
It's always there, like the drip, drip, drip of a faucet. Because it is slow and constant, you often don't know you're hitting that 'brick wall' of depleted energy. It really sucks. You go out with freinds and all of a sudden you have to stop, because the pain has sucked up all of your energy. An analogy I've used in trying to describe it, is that, when people talk about 'running on empty', I have no 'empty' to run on. It's just gone. It has affected and effected my life in ways I never could have imagined.

Dreaming asks, "How much pain is too much pain to live with?" There is the crux of the matter. I'd always had a high threshold for pain. It's really trial and error, especially with the opiates. You have to find that right titration for you, that will dull the pain as much as possible, without dulling your mind (too much).
I think that a large population of PCPs have not been adequeately trained to treat chronic pain-even knowing what questions to be asking. This isn't a knock to the docs out there, but of the system that trains them. I think residency training should have a mandatory roatation in a Pain Clinic to at leastl give them an adequate introduction. UNless one is going into PM&R or Anesthesia, chronic pain mgt. seems to be missing in the residency trainings.

Wendy said...

As someone who has dealt with chronic pain for almost 20 years post MVA trauma & head injury, I think of myself as an educated patient willing to make trade-offs for quality of life.

My current course of treatment: physio weekly, physio specific exercises daily, swimming 5 - 6 times weekly (18 - 25 kilometres/month), light resistance training 2 - 3 times weekly, heat, TENS, trazadone to help with sleep, celebrex, tramacet when required.

The anti-inflammatory allows me to train -- which does immeasurable good for my cardiovascular system and my musculoskeletal system.
Everything's a trade-off.

I have a family physician who understands, works with me and my orthopaedist to allow me the best quality of life possible. And I cannot tell you how thankful I am for that.

Flashtrigger said...

I was incredibly frustrated with a few of my docs last week; two neurologists, specifically. I like your honesty because it reminds me that doctors are human, too. That my docs are just doing the best they can with what they have, that diagnosis isn't always as easy as an ICD-9 book, that maybe I could be a little more pro-active in my own healthcare as well...
I just need to be mindful that as frustrating as it can be for me, as a patient, it's probably just as frustrating for the physician treating me, as well.

Anonymous said...

Dr A - You fail to mention chiropractic care in your blog. Why is that? Proven in low back pain, neck pain and headaches. Clinically successful with extremities. PT and rehabilitation is great, but if the underlying joint is not moving properly, you'll get chronic pain instead of a complete resolution.
Dr. J

Anonymous said...

With this coming from a chronic pain patient, I have to say I mostly side w/ the lawyers. It's pathetic that so many doctors are scared to death of the DEA that they will allow their patients to suffer in pain, and flat out refuse to prescribe any opiate. There are many doctors around my area who will not prescribe opiates even if a patient gets injured! So of course I'd be more likely to side with the lawyers. Sorry but you cannot let your patients suffer. Like I told a million doctors before getting sent to pain management clinic (who've made my back worse), one day you're going to need help w/ pain and nobody is going to help you.

Anonymous said...

Well, doctor, it sounds like you're in a hard spot. The only way this is going to change is for a handful of caring doctors to CHALLENGE the DEA. Remember the main reason you got into the field of medicine was to treat the ailing. When the gov't won't allow you to do your job, don't go cower in a corner. Do the right thing regardless of how hard it might be! Fight for what is right!