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|Newsletters: A Doctor’s Perspective on Pain Management|
A Doctor’s Perspective on Pain Management
Dr. Richard Patt
A growing group of long term HPEN consumers (nearly one-third) have pseudo-obstruction; they have what appears to be a normal bowel in the sense that there is no mechanical interruption, but the musculature or the neurological innervations of the bowel does not work, so it behaves like constant obstruction. It’s a very tough diagnosis to make. Often the patient goes through a lot of frustration before they get a diagnosis. The person with pseudo-obstruction also endures a great deal of pain. Because most serious pain medications impair the motility of the bowel, these consumers are caught between a rock and a hard place. And the issues of addiction further complicate their ability to get any relief from their pain. The following are comments from Dr. Richard Patt’s presentation on pain management given at the 19th Annual Oley Conference, held in San Francisco, CA in June, 2004.
Where We Are and Where We’re Going
We are paradoxically in the midst of a rebound phase and pain management, regrettably, is at a low ebb just now. The 1950s and 60s were an era during which patients with cancer and those at the end of life commonly suffered unremitting pain, despite readily available and inexpensive remedies. Then there were some successful initiatives that arose from several sectors — physicians, nursing associates, patient advocacy groups, and the pharmaceutical industry — with great results in treating pain at the end of life.
Next we asked, “In this country of sophisticated medical care, do we really have to be dying to get comfort and relief from pain?” So we began the next part of the job, the harder part, which was to deal with patients with chronic, painful medical disorders who are not near the end of life. In this setting, we need to be thinking about functional status (performance status) and not just for six days, but for six weeks, six months and even six years — and this raises a lot of issues. Fortunately, to do a better job of controlling pain, it’s not a question of finding a new molecule or a new scientific breakthrough. We have simple tools that work today and have worked for the last 100 years. A lot of so called “new developments” are old drugs in a new package, like Duragesic patches, transdermal Fentanyl and M.S. Contin, an old-time morphine pill in a slow-release preparation. Instead the issues are addiction — real or perceived — and building better physician/patient relationships.
Recently the Joint Commission for Hospital Accreditation (JACHO) insisted that hospitals ask about and respond to people’s pain, but there is no true mandate or accountability. The health care delivery system is broken and we don’t have sufficient time to ask about, or treat, pain.
Professionals are clueless about making the distinction between pain management and drug abuse. We all watch TV and see “Just Say No to Drugs” but it doesn’t say “unless your physician prescribes your medications for a legitimate medical reason.’’ There is a picture of Nancy Reagan and Ronald Reagan on his hospital balcony and he is waving at people on the day of his surgery, but nobody explained he had a spinal morphine catheter in. What about the Rush Limbaugh debacle? While I don’t know all the details, it appeared that this individual was taking mega doses of strong opioides but none the less he appeared to be pretty functional. This is not consistent with the media depiction of a drug addict living a shady existence from fix to fix.
I’m not sure why, but there was a strong negative reaction to the Limbaugh event. The manufacturer of Oxycontin no longer made available the 160 mg dose. The media spread the word, by every possible means, about how any kid could abuse prescription drugs by subverting the system, chewing, breaking up or injecting time-release drugs. So if the kids didn’t know about it, they came to find out about it. Doctors ran in hiding, as there was a great deal of fear of regulatory reprisal. Physicians have been jailed; have been given murder sentences, with an obviously chilling effect on their willingness to adequately care for patients in pain.
Pain: An Invisible Tormentor
There is no blood test or X-ray that determines whether or how much pain you have. My assistant used to say, “If pain was a rash, this would be a no-brainer - everyone could see it.” In some ways, cancer patients’ pain is overt in that at least you can see a tumor. Medical oncologists became our nation’s pain specialists by default. They didn’t apply for the job, they weren’t trained for it and, up until recently, there were no pain management questions on their board exams even though 70 to 90 percent of their patients had pain.
One would think a rheumatologist would be a pain specialist. In my community, an out-of-state relative complained to our medical board about a local rheumatologist’s treatment of a patient. The board is charged with protecting public safety and must respond to every consumer complaint. However, since the board is anxious to get additional funding to pay for its investigations, once they begin one, it’s likely that they will have positive findings. This doctor became very frightened and ultimately took his triplicate prescription books and mailed them to Austin for the investigation. One and a half years later, it’s still in the very first phase of negotiation. Basically, they didn’t understand why a rheumatologist would be prescribing opiates. Unfortunately, because he was a good pain manager, (being the exception and not the rule) and because statistically rheumatologists don’t prescribe a lot of scheduled substances, he was punished for doing a good job. So the pendulum has swung back in the wrong direction and will probably overcorrect in the future. There is no question that we need to be alert to concerns regarding the potential for drug abuse. There are patients who have both a substance abuse and a pain problem. They require special management approaches.
Finding the Sweet Spot
I’d say 80 to 90 percent of my practice consists of regular patients like you and me who are not near the end of their lives. I have a stable group of patients with whom I work. I put a lot of time into the evalution phase, probably three or four hours with a new patient. In my experience this makes it much easier to manage the patient further down the road. I also get the family involved, because I’m interested in their observations, even though the patient is the main authority.
Typically, it takes a lot of work to find the right medications and the right doses. We work hard in the beginning adjusting the medication to get things just right. Once we do, there often is a short period when the individual gets a little greedy and they say, “This is really good, maybe more is better.”
When I‘m following up with a patient I ask, “are you better, worse or the same?” They usually assume I mean is their pain better, worse or the same; but in fact, the question is more relevant to the potential adverse effects of drug X, Y and Z, and ultimately, to their functional status. For example, I ask, “Do you have constipation?” You only have to be on the wrong end of a manual disimpaction once to not want to go there again. There may be a phase where the consumer finds that, with the next step upward in pain control, they have more problems with nausea or grogginess than benefit from relief of pain. With work, however, they find the right balance. My patients have taught me most of what I know, and fortunately I’ve been smart enough to listen. In my experience, once they find that sweet spot where pain is not eliminated, but is tolerable and side effects do not interfere, then the majority of patients will stay at that dosage for months and even years. If there is a need for a sudden dose increase, we look for progression of disease, such as an abscess or obstruction.
If you’re going to get a side effect from an opioid, it’s almost always going to occur at the initiation of therapy, not after prolonged use. Everyone wants to blame the opioid. I’m intentionally not using the word ‘narcotic’ because it conjures up back-alley images.
For someone who’s gotten through five decades or more of their life without a problem with alcohol or drug abuse, it’s a fallacy to think that simple exposure to opioids will produce an addiction syndrome as if by magic. It’s not only wrong, it’s demeaning and it doesn’t say much about what we think about people, and their values, and the strength of their convictions. It should be pointed out that I do not think of these drugs as primarily addictive. I believe people and their coping strategies are potentially addictive in nature. To be fair, you can say it’s the interaction between these substances and our lifestyles that leads to addition. If someone is stressed out or is having a problem, it is not uncommon for them to take a drink, gamble, spend money or choose another poor alternative to an appropriate adult way of managing their stress. These individuals are at greater risk of developing a psychological dependence on opioids. However, as a new behavior this is not common, since the best predictor of future behavior is past behavior.
Addiction is not tolerance. Even if the Pope developed pseudo-obstruction and was experiencing pain and needed opioids, he would eventually become accustomed to the medication, and need a higher dose over time. Galloping tolerance is rare. Tolerance is simply the need for adjustment of dose to maintain a given effect over time. Addiction is not synonymous with physical dependence. Anyone exposed to opioids on a chronic basis that were then abruptly stopped, would develop a syndrome of withdrawal, with a runny nose and other symptoms seen on TV. This can be avoided simply by gradual withdrawal. Typically, we see that patients get off the drug much faster than we, as clinicians, would like. In fact, I spend more of my time helping patients understand that taking these medications is appropriate than I do trying to get patients to turn them down. But patients are reluctant, especially when it comes to drugs like Methadone. We’ve rediscovered Methadone and it’s become one of our drugs of choice. It’s got interesting pain-relieving properties, and it’s cheap, but the whole stigma of drug abuse in methadone maintenance programs makes people reluctant to use this medication.
Honesty in the Physician/Patient Relationship
I gave up a long time ago trying to determine, as someone walks through the door, whether their pain is authentic and how much they hurt. Even after talking to them for hours, it’s hard to know. I choose to believe everything my patient tells me. I’ve learned that addicts, or people who are trying to scam the doctor, declare themselves very quickly with lost prescriptions, tales of ‘the baby threw up on my prescription’ and all sorts of behaviors characteristic of people likely to develop a drug problem. We provide a lot of supervision, observation, and rules for the family, and we encourage people to use journals and logs. This is low-tech but important stuff; it’s simple but requires a mature approach.
One of the most important things for someone with pain is to cultivate and honor the relationship with his or her physician. It is not a good sign if I find myself thinking, “Is that really true? Can I really rely on them when they’re telling me this is the last refill?” Similarly, if the patient finds him or herself thinking, “I hope Dr. Patt believed me. I’m not sure because of the look in his eyes,” there is a problem with the physician/patient relationship. It cannot possibly be therapeutic if it continues this way. The physician should say, “I have trouble believing what you’re telling me. I like you, I respect you, but help me understand this because it doesn’t make sense to me.” On the other hand, if the patient is saying, “Dr. Patt, I feel you don’t believe me,” then it is time to talk it out, deal with it and move forward. If the trusting relationship cannot be reestablished, it’s time to find another doctor.
Keeping it Simple
We keep it simple whenever we can. We know we can give 30 mg. of oral morphine and get the same effects as 10 mg. of IV morphine, though not as quickly; but when treating chronic pain, we’re not interested in a quick fix. In fact, sometimes it’s useful to send the message that pain is not an emergency and should be addressed in a fashion least likely to overshoot the need. An exception is a spinal or epidural morphine pump that is implanted surgically and pumps tiny amounts of morphine into the spinal fluids so that the patient gets profound pain relief with little risk of side effects. The spinal system is more expensive and high-tech than most patients need, but some people, particularly elderly or very ill patients who cannot tolerate medication fluctuations, are excellent candidates. There’s also the individual with the compromised gut, like Oley members; we don’t necessarily rule out using oral drugs with these patients, but we need to recognize that the absorption of pain medication is going to be affected.
We all bring our own styles to bear in clinical relationships, and I’ve come to recognize that I can’t help everyone. This realization has been difficult for me to accept. It’s better from the consumer’s point of view to be the turtle, than the hare; it’s more important to get there over time, than to remain on a roller coaster. You need to set goals, which need to be functional goals, rather than just relief from pain. No matter how good a job I do, all my patients still have pain every day. They have fewer bad days, the bad days are not as disruptive, and they feel more control; but chronic pain at some level continues. It’s a question of bringing it down to an acceptable level for each person, so that even though they still have pain, the pain no longer “has them.”
It is important that we work together honestly to accomplish pain control. Addressing this issue through conferences like the Oley annual meeting is helpful. Thank you for inviting me.
A videotape of Dr. Patt’s presentation is available from the Oley Video/DVD Library, and can be borrowed by calling (800) 776-OLEY. For more information about this topic, read “The Complete Guide to Relieving Cancer Pain and Suffering” (current edition) by Dr. Patt and Susan Lang. (Copyright 2004, Oxford University Press).