Something that pains me.

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“Pain management” the very phrase stirs strong emotions. Everyone in medicine from patients, nursing aids, to CNA’s, nurses, rad techs, paramedics, and doctors (titles listed in order I could think of them, don’t get all crazy with some sort of order of preference) of all specialties.

                About the only things people agree on are a) something should be done about pain and b) nobody is doing the right thing.

                That is strikingly similar to the common conceptions of “Nobody works at work except me” and “Everybody is stupid except for me”.

                The first thing we must understand in controlling pain is that there are different types. The most common pain we think about is nociceptive pain. This is pain that from pain receptors. Like when you smash your finger in a door. However, this pain is not so simple. For example, the same nerve endings that register pain also register cold. Pain receptors, like the cardiac tissue that many emergency providers spent outrageous sums of time learning and professing about, also have action thresholds. This threshold is lowered by the kinin system as part of the inflammatory response. So what appeared as a simple statement on a single type of pain is actually not very simple at all.

                Additionally, there are other types of pain, such as neuropathic pain, when there is abnormality in pain reception and transmission. But perhaps something often over looked is ”remembered” or “anticipated” pain. This is equally a problem both in the acute presentation of pain as well as chronic presentation.

                There was once a theory (which has been completely debunked scientifically) that children would not remember pain.  Primates, who include humans, remember pain in order for self- preservation.  It is a biological survival function. It stops you from putting your hand on the hot stove “again” it causes fear which makes you afraid of the dog or all dogs, because you were once bitten. It is the reason kids don’t like to go to the doctor or dentist because every time they have in the past, pain was part of that experience. This biological programming does not completely go away in adults. But the important point is, you expect it to hurt, and that by itself can cause or amplify pain.

                Anyone who deals regularly with opioid pain medication understands resistance over time, down to the cellular mechanisms of reduced cell surface receptors because of intracellular cascades. (If you haven’t heard one of my lectures, biological processes have been conserved over centuries in all life forms, and so there are patterns which repeat in numerous forms. By understanding and recognizing these patterns, the practice of medicine is considerably simplified, and more effective.)  You can see a similar pattern to opioid resistance in insulin resistance, making the principles of one applicable to the other.

                Another important part of the background on pain is culture. In some cultures pain is a sign of weakness; in others people need permission to feel pain. On the opposite side of the scale, some cultures are very vocal about their pain; those outside of the culture have a very difficult and often biased acceptance of the person’s pain.

                The final piece of the puzzle is the social morals regarding the management of pain. This contributes into provider attitudes towards managing pain. Some providers cite legal responsibility, and I just call malarkey. In the US, abortion was once “illegal” but there were many providers who were putting medical care above the law, which is a time honored tradition in medicine. (whether we agree or not, is not relevant to this discussion) It is very popular in certain countries, such as the US and Poland, for providers to withhold or improperly manage pain based on their moral and sociological perceptions of chronic pain, drug abuse, and overall desirable mating characteristics of patients (see my previous post on this).

                In many countries, it is written and posted that patients have the right to have their pain managed. Whoever came up with this right needs to have a lawyer more clearly define “managed” as there is considerable confusion. Some will say “managed” doesn’t mean any pain, but an acceptable level of pain. Some will say it means it means no pain at all. I tend to interpret the spirit of this “right” to mean, every effort should be used to eliminate pain until the risk of therapy outweighs the benefit. Classic medical risk/reward analysis.

                However, the risks are not simply limited to biomarkers, parameters, patient satisfaction and safety. What I consider an acceptable risk, another provider would consider no risk, or even possibly wanton disregard for patient safety. (In my case, most likely the later.)

                But among other things, risk can be reduced both education and experience. People not experienced at managing pain, will be afraid not of managing pain, but of their unfamiliarity with the means to do it. Having the proper tools, or even more than one tool, readily available also helps.

                The purpose of anesthesia is stated in 3 criteria. 1) The patient does not feel pain. 2) The patient does not react to pain. 3) The patient does not remember pain. It doesn’t get much simpler than that. It means, no pain. We also define analgesia. There are several variations of the definition available, but I think this one,  from the freedictionary.com sums it up the best.  “A deadening or absence of the sense of pain without loss of consciousness.” Most of the other variations mention only the complete absence of pain while maintaining consciousness. But this definition is not the(a) theory like the purpose of anesthesia. It has very specific criteria.

                So does analgesia have the same theory as anesthesia? You bet it does! Don’t believe me, go to the dentist and ask him to drill away. It won’t take too long for you to decide you don’t want to feel that. Go and have your appendix removed or a fractured bone reset, decline anesthesia. Be a boss and simply tell the anesthesiologist, “No thanks, I got this…” The next time you have a headache, tough out the rest of your day at work. I also don’t want to hear any misogynous remarks about “walking off the pain,” or “manning up.”

                In medicine we often profess that the whole patient must be treated. It seems to mean in relation to pain too. You can’t just treat nociceptive pain and call that management. Because it means that all other pain was not treated. In modern times, especially in pediatrics, every effort is made to reduce remembered pain. Neuropathic pain is also its own monster.

                In the EMS world, an antagonist of mine is often quoted as saying “Extreme pain + 2mg of morphine= extreme pain.” That actually very accurately describes my thoughts on it as well. Most Emergency providers, whether in EMS, fire, or even the ED, don’t know that opioids come with a weight based dosage. (0.10-0.15 mg/kg for morphine) More practically 1mg/10 kg or 1.5mg/10 kg if it is really bad. You can look up the weight based dosages for whatever you like to use or is available to you. Some providers claim that bolus dosing is dangerous and should be avoided, and I tend to agree with them, but these weight based ranges are still a good indicator of how much you can expect to need in the end. In my experience using procedural sedation (conscious sedation) these are actually minimum doses that seem to work, under another dosing technique called “titrate to desired effect.”

                  However, for all this discussion on morphine, opioids only really work on nociceptive pain. Other medications and techniques are needed for the other types for total pain management. I have found using small doses of benzodiazepines in addition to opioids actually helps deal with the remembered pain too, especially in peds. We do not want children to be afraid to go to the doctor or hospital remembering it hurts. There are also pathophysiologic effects of pain. Some providers prefer ketamine. One of my best teachers in medical school was an anesthesiology professor who professed “There are many ways in anesthesia to achieve the same thing. It is impossible to know and be competent with them all, therefore, pick a few that you like, and stick with them.” The same pattern holds true in the pursuit of martial arts. Each style has hundreds of techniques and variations. If you are in a fight, standing around deciding which technique you want to use probably isn’t going to work so well if you plan to win. But I digress… There is more than one way to be effective. But you need more than one choice, because well… its medicine, and nothing works 100%.

                In practical terms for providers, pain usually comes in 3 kinds, chronic pain, acute pain, and irretractable pain. This is where I think all of the problems actually occur. 1st, people with no idea about pain control or practical pain control, make up restrictions based on fear and not reason. Call them joint commission, your medical director, professor, or whatever.  This comes in the form of ineffective drugs, dosing, and techniques. 2nd is provider accessibility. If controlling a patient’s pain creates pain for providers, they simply are going to find justifiable reasons not to. 3rd is the providers moral objections, you know, “the patient is a seeker,” “the patient is an addict,” “the patient is undesirable for X reason.”

                Let us look at these “undesirable” patients. Is being an addict a choice? Perhaps at first, when the need to seek pharmacological support to deal with socio-economic or psychological issues, is required.  At some point though, it becomes a physical dependence and at that point, medical palliation is required. I purposely do not call it medical care, because effective rehab and manipulating the environment that caused it is beyond the scope and ability medical provider.

                Going back again to my fire service roots, one of the things I learned in fire/arson investigation class was “bad things happen to bad people too.” In context, it was to point out not to automatically think a fire which involves a criminal or other morally objectionable person was the result of arson. In relation to pain, the same thing applies. An addict, seeker, chronic pain sufferer, etc., may really be in pain. But these conditions do not preclude them from the patient rights of having their pain managed. Some providers are adamant that the emergency system should not be involved in that.

                This begs the question, whose job is it? The logical answer would be a pain management specialist. However, there is a major question of access to these specialists. In the US, this access is limited by the ability to pay. In other countries it is limited first by the few pain specialists, and second by the inability to be productive or even maintain basic function while navigating a cumbersome system. Consequently, the common people dealing with pain are 1) The patient themselves, either by nonprescription medication or illegal means of obtaining drugs, whether sharing prescriptions, or more elicit means). 2)Primary care providers, whose knowledge, techniques, and time are limited, but none- the-less are morally, ethically, and in some cases legally burdened with a duty to act. 3) Emergency providers.

                I have had the experience of having a patient show up at a clinic I was at with an official US prescription bottle that looked more like a soda bottle than prescription bottle because of its size. It was an official prescription, with the prescribing doctor’s name, dosage, filling pharmacy, date filled and everything for morphine, 20mg, 3 times daily, 6 months supply. It was empty one month since it was last filled. For many years I have professed the physical exam and history of a patient is not a mystery to be solved. It is an interrogation and the desired outcome is confession. His initial story was the “pills were stolen.” Because you know, when you steal 450 pills of morphine, leaving the bottle behind makes it easier to get away and it takes longer for the patient to notice the pills are gone right? (I didn’t buy that story either) So I took him to my office and offered to do my best for him, but I wanted the truth. He then volunteered that he needed to take more than 3 a day to make the pain go away and that he had been having the same primary care provider treat him for years with this. I asked him what type of work he did, and he told me he was an aircraft mechanic! That takes the phrase “fly the friendly skies” to another level. I explained to him, that not only was I not going to refill his prescription, but that he could not continue to work in his current position. He then gave me a very sincere sob story about needing the money for family, etc. In the end, it was decided that he would return home without a prescription and look into temporary or permanent disability. I took it upon myself to call the doctor who prescribed it and ask him if he knew his patient was a civilian aircraft mechanic. (From his reaction I am guessing he didn’t) This doctor very humbly concluded qualifying the patient for disability would be a better plan.

                This experience aside, I have talked to a few primary care providers about pain control, and their almost universal response (imagine getting nearly the same response from multiple doctors) is “We have to do something, opioids are our best/cheapest option.” Stands to reason if the patient cannot have specialist treatment for whatever the reason, less effective treatment will be the only option. But this is not curative treatment, this is palliation.

                So that leaves the emergency system. Whether EMS, the fire department, or the emergency room. (A&E for the British friends) people with chronic pain and addiction use these resources for help. Just as for many other conditions, emergency is an extremely ineffective form of help. (One of the many reasons I am convinced Emergency Medicine should not really be a medical specialty, with no ill reflection on the ability of the many great doctors that “practice” it)Some emergency rooms have taken to posting signs stating they will deny patients effective pain treatment. Some believe that simply referring a patient to another doctor will suddenly solve all of the access issues around chronic pain management. Some actually profess they are not a drug supplier for the undesirable. But the bottom line of all of this is: They have chosen not only to deny patients their right to pain treatment, but to deny them any effective help at all.

                Generally in medicine when you cannot best treat the patient, you refer them. Understanding the access issues above, when was the last time you saw an emergency physician ask for an immediate consult from anesthesia or PM&R at even 1pm in the afternoon much less 3am? I have never.

                When an alcohol addict is admitted to the hospital, in order to treat their physical addiction, they are given either alcohol or benzodiazepines. When an addict of any drug requires surgery (not to be confused with elects surgery) in order to reduce complications both surgeons and anesthesiologists maintain their addiction.

                Taken as a whole that means your GP, your surgeon, and your anesthesiologist will not only treat your pain, but also palliate your addiction in the name of best and safest practice. The response from emergency? “Fuck you, undesirable, we aren’t doing shit for you or your addiction.”

                Not exactly altruism.

                Maybe “come back here when you are dying and I will make an effort for you then.” So much for prevention and promotion. Probably good they don’t say that to patients presenting with chest pain!

                People do not choose to become addicts anymore or different than they choose to have coronary artery disease. But yet one is treated much differently than the other?

                We have all heard the phrase “Primum non nocere,” many of us profess it. But never give a thought as to what it means. It doesn’t say “do not harm people with medical treatment or diagnostics.” The scope is much broader. One might even conclude it means do not harm patients by forcing them to palliate their addiction on the street, which is dangerous, unreliable, and criminal. (Forcing people to become a criminal is causing harm.) If they are arrested their social problems increase. If they are jailed, further health and safety is at risk. Do I really need to describe the dangers of criminal life on the street and the composition of the drugs found there?

                Has anyone considered that alienating and ostracizing people addicted to drugs, because of pain they really have or life they cannot cope with, actually promotes their dependence and lessens the chance they will seek help in the future?

                This all seems to me like one of the most simple aspects of medicine, relieving pain, is perhaps the single biggest failure of medical providers around the world.  Providers and institutions need to start getting their act together. If they are not going to actually help, they should start by first doing no harm. Keeping in mind bad things happen to bad people, but we should not be prejudiced towards them.            

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