The Painfully Fine Line of Pain Management
Updated: Dec 14, 2018
(as published on KevinMD.com on June 2, 2018)
I’ve been practicing as an interventional pain management physician for over six years. It was a long road to get here — four years of medical school, four years of residency in anesthesiology and one year of fellowship (in addition to the four years of undergraduate education). So people say, “You must really love what you do.” Sure, during residency there was light at the end of the grueling tunnel with the prospect of a year fellowship. And during fellowship, it was great to learn all sort of techniques to help manage chronic pain. But then, after fellowship, I was thrust into the “real world” where writing prescriptions for opioids was the norm. In fellowship, we were taught to treat the patient, educate the patient on the dangers of opioids and offer interventions to help alleviate their pain. But suddenly, in the real world, it was expected that I would hand out prescriptions because if I didn’t — patients would not return.
I say this all as a preface so you can understand how challenging it is in today’s society to manage chronic pain. According to the CDC, deaths from opioid overdose continue to rise. The total number of opioid prescriptions dispensed peaked in 2012 at a staggering 255 million. Houston, we have a problem!
But what about those patients who truly need these prescriptions?
Sally (identifying information changed) comes into my office. She has a diagnosis of degenerative disc disease of her spine (arthritis in the discs of the spine). She’s had many MRIs over the years with no significant change. I pull up her database (prescription monitoring database — many states utilize but unfortunately not all states, and not all states are linked together) and notice that she’s been on a variety of medication including long-acting morphine, long-acting Oxycodone, even a few prescriptions of the super strong hydromorphone (Dilaudid). I ask her why she is on such strong medications, and she laments that she needs these medications to function. She has no quality of life. She has not worked in 20 years. She is not active. She is morbidly obese. She sits at home all day long and watches TV and eats because moving hurts. I tell her that medications are not the answer, and that part of the problem if not the main problem is that she is inactive, obese, and these medications contribute to her amotivation. She immediately lashes out at me, says I’m a horrible doctor and not compassionate, then asks me if that means I’m not going to give her the prescriptions she needs. 20 minutes later, I receive one-star reviews on Google, WebMD, and Vitals — all blasting me for being a horrible doctor.
Debbie has pancreatic cancer that has metastasized to her lymph nodes. She occasionally has blockages of her bile duct that requires a procedure to open it up. She is also undergoing chemotherapy and has just completed radiation therapy. Every time she comes in, she’s the face of optimism. She is determined to get through this. She doesn’t want to take pain medications because they make her feel loopy. Even when I prescribe them to her, she takes as few of them as possible. I asked her to bring her daughter in for one of the visits so I could talk to them both. I explain that there is nothing wrong with managing the pain. Debbie is clearly uncomfortable due to the pain but smiles throughout the visit. I prescribed a low dose Fentanyl patch that she can place transdermally and change it out every three days. I also prescribed a short-acting opioid medication, Hydrocodone (Norco), that she can take every eight hours as needed for breakthrough pain. Two weeks later, I see them both back in my office, and Debbie is smiling cheek to cheek. She feels great, and the pain is under much better control and she loves that she doesn’t have to worry about taking pills. She brings back her bottle of Norco which is over half full.
In my training, I was taught to follow the World Health Organization stepwise management of pain when it comes to opioid prescriptions but that opioids were indicated specifically for cancer pain; it got trickier to manage chronic non-cancer pain. Even so, it was a stepwise approach to managing pain – always start low and titrate up as needed. I can’t tell you how many times I’ve seen patients come to me who have been given 240 pills a month of opioids, or a combination of long-acting and short-acting opioids well above the recommended 50 MME (morphine equivalents) for non-cancer pain.
For patients with cancer, I treat liberally for pain (and I use the term liberally quite loosely); however, I’ve found that that particular set of patients are the ones who ironically don’t want to take medications. But when I gently nudge/insist that it’s OK to treat their pain, they are the ones who are the most grateful. Of course, it’s not always black and white. Yes, people with cancer can get addicted to opioids as well.
Sometimes I find that managing chronic pain can be a bit of a dance between myself and the patient. Sometimes a little bit of a compromise. I always tell my patients that pain is subjective but many things can contribute to pain — certainly stress, lack of sleep, any emotional issues can make pain worse. Your pain is different than my pain. I don’t like to use the word “tolerance” when it comes to opioids, but certainly, some people are able to tolerate pain more than others. But it does go back to the emotional component related to pain. One of my attendings in fellowship — known to be a bit of a hard ass — used to tell our patients, you can’t die from pain. Your blood pressure that’s 210/110? That can kill you. The 100 percent blockage of your artery in your heart? That can most certainly kill you. Your smoking four packs a day? That may kill you. Your pain is a by-product of your experience. Snowing yourself with opioids only tricks your body into believing there’s nothing more serious going on. And it’s a temporary solution for a more permanent problem.
I didn’t think I would be disillusioned with my career only six years into it, but this epidemic is pretty serious, and really the only way to move past this is to educate, educate, educate on the dangers of opioids but also the benefits of opioids in the right setting. Interestingly, most lay people do not know that the field of interventional pain management exists. We are not pill mills. Many patients I have talked to who finally come to see me for an epidural steroid injection (among other injections I perform) have gone from their primary care physician to a spine surgeon for surgery without any in-between. Education comes not only to the public but to our fellow physicians. There are many aspects of my job that I enjoy. I enjoy helping a patient get over that hump with a combination of the right medications, injections, and physical therapy. I enjoy helping patients like Debbie get a good quality of life in spite of her cancer. It is a fine line when it comes to pain management, but that doesn’t mean that it’s an impossible hurdle to get past this epidemic.