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.