Pain management
I view it as a duty and privilege to adequately control pain in my patients. It is imperative that the patients take an active role in their health as well, however. Just writing a prescription is not sufficient therapy for many chronically painful conditions. If back or leg pain is present in the setting of obesity, then weight loss is just as important as pharmaceuticals. Physical therapy and exercise, in most cases, are essential. Maintaining functionality, including continuing employment when at all possible, is important not only for psychosocial and financial reasons but to promote structure and a positive self-image. The natural release of endorphins one achieves with a satisfactory family/job/exercise situation is more effective long-term than just narcing someone up and letting them get fatter, lazier, and more withdrawn from society. Depression is frequently present and must be treated as well.
Opioids are important, but they need to be used wisely...with the goal of maximizing potential. Pain relief should be an intermediate goal, not the ultimate goal. The ultimate goal is return to function. Anyone can be made comfortable with medication, but if they are just a comfortable blob nodding off on the couch, why bother?
Pain management needs to be directed by one physician, but in certain cases a multispecialty approach can be helpful (Ortho/Neuro/Psych, for example). A carefully worded pain management contract, where the patient agrees to be honest about his compliance with therapy and the medications he obtains, is mandatory. Visits to the ER for breakthrough pain should be rare, not routine. It must be made clear that lost or stolen prescriptions will not be replaced, and that changes in the amounts of medications taken must be approved by the managing physician. The patient therefore is involved with the plan, and shares some responsibility for getting better.
The goal should be to get better, not just to feel better.
Opioids are important, but they need to be used wisely...with the goal of maximizing potential. Pain relief should be an intermediate goal, not the ultimate goal. The ultimate goal is return to function. Anyone can be made comfortable with medication, but if they are just a comfortable blob nodding off on the couch, why bother?
Pain management needs to be directed by one physician, but in certain cases a multispecialty approach can be helpful (Ortho/Neuro/Psych, for example). A carefully worded pain management contract, where the patient agrees to be honest about his compliance with therapy and the medications he obtains, is mandatory. Visits to the ER for breakthrough pain should be rare, not routine. It must be made clear that lost or stolen prescriptions will not be replaced, and that changes in the amounts of medications taken must be approved by the managing physician. The patient therefore is involved with the plan, and shares some responsibility for getting better.
The goal should be to get better, not just to feel better.
posted by scalpel at 12:23 AM
6 Comments:
Excellent plan. I think it's a travesty when doctors put their own litigious fears above what's doing right by the patient. When pain is no longer a useful warning sign, it should be reduced as much as possible since it serves no purpose anymore. I understand an ER setting is particularly iffy because you don't know a pt's "true" history, but I'd like to think that short of obvious signs to the contrary, the patient should be given the benefit of the doubt and given enough pain relief/outpatient rx of a reasonable length to last until they can be seen by their main Dr (not always possible the very next day due to scheduling). That's my perhaps naive view as a med student, anyway.
I just found your site last night and read every entry. I lived in Houston for 12 years, off and on (most recently in Meyerland/Bellaire)--it is where I call home. Don't know if I'll select a residency @TMC...I really like H-town, but I have this thing with heat and humidity. Go figure.
Pain management is very important, but do you find in your field that people use medication to function? For example, I recently tore, well, pulled this time, ligaments in my left foot, and instead of getting medication, which I probably needed for a day or two, I opted not to because I use them to work. I tend to ignore the problem and attempt to go on with work, school, etc... I have chronic injury to my ankle/foot, but in the past never approached it like this time. See, now I can feel it, and it forces me to slow down, and deal with the rehab and the healing part. Also, I have a fear of dependancy because I have been dependant in the past. Am I crazy for being in so much pain? I haven't been nauseaous (sp) this time, so I feel that's a good sign, but man, I hurt so much.
It's not inappropriate to use medication to improve function. In fact, that is the goal of medical therapy.
For an acute traumatic injury, however, medication should not be used in place of appropriate rest or immobilization, otherwise one risks exacerbating the injury.
Patients who have a painful condition and take their medication as prescribed to relieve pain rarely become addicted. The ability of patients to tolerate pain, and their desire for narcotics varies greatly.
In my experience/opinion, it seems that many patients with chronic painful conditions of unclear etiology (fibromyalgia, some chronic back pain, and atypical "migraines" for example) who require large amounts of narcotics often have rather low tolerances for pain, and the true pathology may in fact be a hypersensitivity to what most would consider normal stimuli.
Ironically, these patients will usually claim that they have a "high pain tolerance" when in fact the opposite is true. They do tend to have high narcotic tolerances though. People with truly high pain tolerances don't often require narcotics at all.
Agree without reservation.
I would like to add, that the current witch-hunt by the DEA against Drs. who specialize in pain management is absurd and counter-productive.
In our ER, we try not to play the cop. We treat pain as any other complaint that comes in the door; determine etiology, treat condition, refer to appropriate service for follow-up. Unless a patient is explicitly and obviously drug-seeking, we treat first and ask questions later.
I'd like to remind everyone of a recent study demonstrating that very few patients treated for actual pain actually become abusers; the main people to worry about are previous addicts who need medical pain control. Hmm, can't find the study, here's a relevant editorial (PDF) http://scholar.google.com/url?sa=U&q=http://painandthelaw.org/aslme_content/24-4c/portenoy.pdf
I love the way you write and have been working my way through your archives whenever I have time. This post really resonated with me as I have chronic pain.
On my list of things to do next year: Go see a pain specialist.
Being a (non-practicing because of the pain) massage therapist, I do pretty good with the self-care, but I've reached my limits. I have trigger points all over my body and it sure would be nice to have some help.
I'd like to go to Grad school, but don't see how I could handle the reading and writing without help--it's too much for my neck and arm.
But first I have to get some other medical stuff out of the way.
Then the pain specialist and then the GRE and then, Gods willing, grad school.
Thanks for the post and your eloquent writing.
M
Absolutley!
I have the unfortunate luck to suffer from migraines on a somewhat regular basis. Most of the time, they can are dealt with using Imitrex before the pain starts, and T4s if the pain does start.
At one point, when I was a young migraine guy, and under what I would now consider very poor care, I was prescribed everything under the book and then headed to the ER about 1 time a week when that didn't work. I must have been just "loved" by the ER staff there!
Fast forward 3 years and I move to a new city, get a new doctor whose first move was to tell me to get in better shape, pay attention to triggers, etc. etc.
From that time on (12 years now), I have been to the ER once for a severe migraine. I found this blog actually because I felt very guilty about being there for an non critical issue and was interested in seeing how ER staff felt about this.
Essentially though, a patient that is interested in their own well being and a healthy lifestyle, in the hands of a medical doctor who is knowledgeable is going to do far better than the patient who demands stronger and more frequent doses of whatever the latest chemical of the day is. God only knows, I would probably be taking heroin now to "manage" my pain had I not listened to doctor #2.
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