Archives for September, 2010

Pain and Judgment in the ER

Thank you to those who have commented;  the pain topic seems to strike a chord that rings differently for different individuals.  Because it is late and I am only now getting to a post that I intended to write hours ago, I’ll use this post to respond to a couple of the comments.

One person believes that pain medications are under-prescribed, and resents the air of suspicion that hangs over legitimate ER visits for painful injuries.  I concur and sympathize in regard to the suspicion.  The writer mentions that laborers are particularly susceptible to injury and, perhaps in part because of their blue-collar positions or 'rugged appearance,' fall under greater suspicion for misuse of pain medications.

I believe that his perceptions are accurate, and agree that doctors tend to separate patients-- consciously or unconsciously-- into 'good patients' who are trusted and 'difficult patients' who must earn that trust. 
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The Tolerance Problem

In my last post I described two common story lines in news columns about opioid dependence; the doctor-shopping pain pill addict and the pill-pushing physician. I described how the truth is more complicated than news articles often suggest. Doctor-shopping pain patients are in many cases people seeking relief for pain that they consider genuine, and it may be presumptuous for someone else to decide that their pain does not warrant treatment. And pill-pushing doctors, at least in some cases, may be the only doctors in a particular area willing to prescribe pain medication for those who truly need them; the doctors unable to turn away suffering patients, even to protect their own reputations and licenses.

Another scenario involving pain medication does not fall under either of the above categories; patients with severe, chronic, nonmalignant pain.
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Does This Hurt?

Every day brings a new set of headlines about the epidemic of opioid dependence.  The stories usually take one of two positions.  One common story line is to blame people who seek out pain pills from multiple sources, ‘doctor shopping’ to obtain a number of prescriptions.  The people seeking these medications use them or sell them, but in either case the implication is that the people who doctor-shop are not seeking ‘legitimate’ pain relief.

Newspaper stories often keep things simple by ignoring the other people; those who doctor-shop because they believe it to be the only way to find adequate pain relief.
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Blissful Ignorance

Thanks for the feedback so far-- one of the comments included a question about depression and drinking:  I don’t drink at all – haven’t for 25 years – by choice, not because I had a problem… Could you explain to me why it is that when I am felling depressed… I feel like drinking?  It is a very strong urge and it takes a lot of work to not go to the liquor store.

The question fits nicely with the situation with our fictional pain patient.  Before commenting I need to point out that I am sharing my thoughts about addiction and psychiatry based on my personal, subjective experiences—not based on scientific research.  I don’t know, to be honest, whether anyone studies addiction from the perspective I’m trying to share, and I’m not even sure how such studies would be accomplished.  But from my way of thinking, the main goal of a person suffering from addiction is to reduce awareness of the pain of day-to-day life.

On the surface, this explanation appears obvious; people drink or use drugs to feel good—no kidding!    But I think that the mainstream perception of this explanation incorrectly implies a conscious or intentional process, and also grossly underestimates the ubiquitous nature of the desire to remain unaware.
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Living On Two Levels

When we left our fictional patient with back pain, she had become tolerant to hydrocodone prescribed by her doctor, and because she was taking more of the ineffective medication, she ran out of medication earlier than planned.  To her relief, she found some tablets of oxycodone in the back of her medicine cabinet, left over from surgery a year earlier.

Our patient had read newspaper articles about the increase in opioid dependence throughout the US, but assured herself that she was not one of ‘those people.’  After all, she was taking the medication to treat pain, not to get ‘high.’
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Tolerance Develops

I described what initially happens when a person with back pain goes to the doctor for pain relief.  The doctor has concerns about being a pushover for prescribing narcotics, and is worried that the patient will become addicted to the narcotic pain medications.  So the doctor prescribes a small amount of pain medication and wishes the patient well.

Back pain can be caused by many different types of injury.  Most commonly the pain comes from tight, overworked muscles or from inflamed tendons or ligaments that have been stretched or torn on a microscopic level.

Sometimes the ‘discs’ that cushions the bony spine will become compressed and develop bulges called ‘herniations,’ that press against nerves that extend down the leg, causing pain in the legs called ‘sciatica.’  Most of these injuries cannot be fixed, but instead must run their course over weeks to months.  Pain medications relieve symptoms, but do nothing to speed healing.  In fact, a situation can be made worse by pain pills, if they allow the person to engage in activities that cause greater injury.
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The Pain Pill Pattern

I’ve been writing about my own progression from a person who seemed—at least on the outside—to‘have it all’ to a person struggling with opioid dependence.  There are so many aspects of the disease of opioid dependence that I hope to share through this blog.

I plan to describe the way I changed in response to becoming addicted to opioids—in ways that are virtually universal between all opioid addicts.  I will write about the different treatments for opioid dependence and for addiction in general, and describe how the newer treatments clash with traditional treatment approaches.  I’ll write about the current epidemic of addiction to pain pills that has resulted in a great many deaths of young people; a fatal epidemic that has killed multiples of those killed by more ‘mainstream’ epidemics like swine flu, yet continues to fly under the radar.

I’ll write about the approaches that are currently being discussed within the FDA and other governmental agencies to try to stem the epidemic; measures that will likely have significant effects on most physicians and on patients who struggle with pain disorders.

How is that for a teaser?!
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Got Desperation?

Doctors sometimes joke about how our medical specialties affect how we view the world.  When I was an anesthesiologist, I became more and more aware of ‘the airway,’ a collection of anatomical findings that predict whether a person is easy to intubate—the term for inserting a breathing tube into the trachea.

In anesthesia, securing the airway is the ultimate concern, and most anesthesia injuries occur from ‘losing the airway,’ leading to brain damage or death from hypoxia.  Airway assessment is an important part of an anesthesiologist’s pre-op assessment, and eventually becomes unconscious and automatic. 
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