Doctors and pain patients: Conflict and collaboration

It seems more folks are starting to see that our current medical system and its methods have made doctors and patients into adversaries. Both initially assume the other isn’t truthful, is either maximizing (patient) or minimizing (doctors) pain.

It’s become a contest: patients want the pain relief opioids provide and doctors want to avoid prescribing them. Both parties have valid reasons for their views and both have valid reasons to distrust the other, a sorry situation for all fo us.

Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care – PubMed – free full-text /25261714/ – Dec 2014 

Diagnosing Hyperalgesia to Limit Care

Misuse of Hyperalgesia to Limit Care | Practical Pain Mgmt | By Donald C. Harper, MD, BSc – March 2011

John (not his real name) is a 51-year-old chronic pain patient that I have been seeing since 2003. I had begun carefully titrating him on oxycodone, Oxycontin® and Dilaudid®, which had been started by another doctor and, ultimately, settled on a dose of Oxycontin 640mg B.I.D., 32mg hydromorphone q 4 hrs prn breakthrough pain and Xanax® 1 to 1.5mg q.i.d. prn muscle spasms and anxiety. On these medicines, he was content and functional and denied any deficits or side-effects due to his medicine.

His insurance company was concerned about the expenses of his medicine and asked me to arrange for a second opinion. Given the complicating factor of his end-stage lung cancer, I arranged for an evaluation by the pain clinic of a major cancer center.  

History of Pain: The Nature of Pain

History of Pain: The Nature of Pain – Practical Pain Management – November 21, 2013  

This is a long, informative article explaining how pain happens.

Our thinking regarding the nature of pain has shifted over the past four centuries from the linear dualistic concepts of Descartes to the Gate Control Theory of Pain, a more global model that includes affective components of pain

The evolution of scientific research has helped us appreciate that the pain experience is more complex and highly multifaceted from the subjective to the specific.

This article will discuss the nature of pain with some general assumptions based on our current understanding and then move to more specific considerations.  

Misuse of Hyperalgesia to Limit Care

Misuse of Hyperalgesia to Limit Care | Practical Pain Mgmt | March 2011

John (not his real name) is a 51-year-old chronic pain patient that I have been seeing since 2003. I had begun carefully titrating him on oxycodone, Oxycontin® and Dilaudid®, which had been started by another doctor and, ultimately, settled on a dose of Oxycontin 640mg B.I.D., 32mg hydromorphone q 4 hrs prn breakthrough pain and Xanax® 1 to 1.5mg q.i.d. prn muscle spasms and anxiety. On these medicines, he was content and functional and denied any deficits or side-effects due to his medicine.

His insurance company was concerned about the expenses of his medicine and asked me to arrange for a second opinion. Given the complicating factor of his end-stage lung cancer, I arranged for an evaluation by the pain clinic of a major cancer center.  

Opioids Disturb Hormones, but Function Improves

Study Suggests High – Dose Opioids Disturb Hormones Long Term, but Mental and Physiologic Function Improves   April 11, 2013

Notice the high number number of patients (all) reporting significant improvement in quality of life, versus how many also showed hormonal disruption.  The hormonal disruption definitely didn’t affect their quality of life as much as pain did.

Half of patients … had hormonal disturbances or signs of inflammation, while 100% reported improved pain control and mental outlook.

The results present rare data on the effects of opioids beyond 10 years. Most clinical trials that examine opioid use are of short duration, and little is known about long – term outcomes, particularly in patients who suffer from noncancer pain.

Therapeutic “Tolerance” in Medical Pain Management

Editor’s Memo: We Need More “Tolerance” in Medical Pain Management

Every time I hear a clamor for dosage restrictions of opioids or hear such statements as “no one could possibly take that much medication,” I suspect the person uttering the statement is pretty ignorant about therapeutic tolerance and the legitimate need for opioid dosage escalation in selected patients.

What is Tolerance?

Let’s review. According to the American Pain Society, therapeutic tolerance is defined as “a state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the opioid effects over time.”1 This is not to be confused with physical dependence or addiction, which are defined in the Table below.

Neuropathic pain: mechanisms and their clinical implications

Neuropathic pain: mechanisms and their clinical implications | BMJ

Neuropathic pain can develop after nerve injury, when deleterious changes occur in injured neurons and along nociceptive and descending modulatory pathways in the central nervous system.

The myriad neurotransmitters and other substances involved in the development and maintenance of neuropathic pain also play a part in other neurobiological disorders.

Intractable Pain: Time To Understand the Term

Editor’s Memo: Intractable Pain: Time To Understand and Use the Term (Again)

I have been hearing the term “intractable pain” (IP) to refer to patients with chronic pain more often of late. To me, it’s about time, as it conveys a simple, needed message—is the pain curable or incurable. Now is a good time to review the history and origin of this term.

In contrast to most pain terms developed by academics that describe the type (or cause) of pain, such as neuropathic, nociceptive, visceral, myofascial, the term IP was used by the Federation of State Medical Boards in 1985 when they created guidelines for the treatment of chronic intractable pain. In 1990, Texas and California both passed Intractable Pain Acts(Table 1).

Opioid and adjuvant analgesics: compared and contrasted

Opioid and adjuvant analgesics: compared and contrasted. [Am J Hosp Palliat Care. 2011] – PubMed – NCBI

Pain patients are usually prescribed additional medications to reduce their need for opiates, despite the known toxicity of these adjuvant analgesics.

An adjuvant (or co-analgesic) is a drug that in its pharmacological characteristic is not necessarily primarily identified as an analgesic in nature but that has been found in clinical practice to have either an independent analgesic effect or additive analgesic properties when used with opioids.

The therapeutic role of adjuvant analgesics (AAs) is to increase the therapeutic index of opioids by a dose-sparing effect, add a unique analgesic action in opioid-resistant pain, or reduce opioid side effects.

A notable difference between opioids and AAs is that unlike opioids some AAs are associated with permanent organ toxicity, for example, nonsteroidal anti-inflammatory drugs (NSAIDs) and renal failure

Chronic pain statistic called exaggerated, misleading

Side Effects | Watchdog Report – Chronic pain statistic called exaggerated, misleading

When faced with intense criticism for her agency’s approval of the powerful narcotic painkiller Zohydro, U.S. Food and Drug Administration Commissioner Margaret Hamburg turned to a sobering statistic:100 million Americans are suffering from severe chronic pain, she said.

The 100 million figure has become a central part of the debate over the use of narcotic painkillers.

That number — the equivalent of more than 40% of the U.S. adult population — is exaggerated and misleading, according to pain experts familiar with how it was derived.

An unfortunate side-effect of modern heath care is that it views all patients in terms of standard categories, even while scientists are learning of more and more individual differences.  The makeup of our genetics, epi-genetics, and even gut-bacteria cause a wide variety of responses to both pain and its treatments.