Pain is one particular area where I find many colleagues woefully lacking in understanding, let alone empathy. There’s something so terrible and so maddening about intolerable, unrelenting pain. It’s interesting that we can remember having pain but we cannot recall feeling pain. The brain simply does not store the memory of pain as it would the taste of banana cream pie or the feel of silk. I believe that’s because there’s something so unbearable and forbidding about severe pain that the brain protects itself by abolishing any direct memory.
At the same time, pain is the one feature of illness that we have a huge armamentarium of narcotics and analgesics to help alleviate. So how come many patients are writhing and groaning in pain? Why do such large numbers of patients who are interviewed after discharge from the hospital report they were inadequately medicated for pain during their hospital stay?
Unless you have actually experienced surgical pain (which many younger physicians have not yet), there is no way you can relate to the profound distress of pain. As I go on rounds in my own Department to review the hospital charts and condition of our in-patient population, an observation I make is that many patients are inadequately medicated for pain. Physicians will give all sorts of excuses. Some of my favorites are: “I don’t want to mask any symptoms the patient may be having.” Another is: “Well, I want to gauge how well he’s recovering from surgery.” And the best: “I don’t want my patient addicted to pain medicine.”
A little background on narcotic medications. There are dozens of them and they come in every possible combination and strength. There are oral tablets, capsules, inhalants, intravenous forms, intramuscular injections, and skin patches to name the most frequently used modalities. Narcotics do an excellent job of reducing pain or somehow making our individual perception of pain less prominent in our consciousness. Of course, if you give a patient narcotics there’s always a risk of making her or him too sleepy or even depressing respirations. Obviously the latter would be undesirable, and we want to avoid that from happening. There’s something unique about narcotics, however. We have a magnificent antidote for narcotics called naloxone (it often goes by the trade name Narcan). Naloxone has an affinity for the opiate receptor sites that is two hundred times stronger than morphine! Naloxone can rapidly and efficiently reverse the effect of any opiate. In a matter of minutes (sometimes even seconds), you can return any patient to a nonnarcotized, baseline state. This means that if I’m ever concerned about whether I’m seeing the side-effects and manifestations of opiates versus, say, an actual decrease in the mental status, I have a fail-proof test: give some naloxone and note the response. If there is none, then it’s not the effect of opiates.
Let me also add a note here about the widespread usage of non-steroidal anti-inflammatory drugs, so called NSAIDs. These drugs are derivatives of aspirinlike compounds such as Advil, Motrin, Naproxysyn, Aleve, and some more recently notorious ones such as Celebrex. They affect pain perception by a completely different route than narcotics.
As their names suggests, NSAIDs were designed to reduce the body’s inflammatory responses. Naturally, excessive inflammation can produce pain; so reducing it at a particular site can have a secondary effect of diminishing it. However, quite frequently patients are given NSAIDs as an alternative to pain medication, or as substitution for it, and that can often be a cruel trick. The reason for this is that doctors have become very leery about prescribing narcotics. The federal government has cracked down on abuse of prescription drugs. Government authorities can now track computerized requests for narcotics at almost any pharmacy in the country.
Doctors have gotten somewhat paranoid about this. Often for good reason. An acquaintance of mine who was a pain specialist was arrested at her home, hauled away in front of her children in handcuffs by Drug Enforcement Agency agents, and placed in jail. Why? Because the DEA’s routine computer surveillance indicated that she was prescribing narcotics far more than the average physician in her region. Why was that? Because, in fact, her specialty was the treatment of chronic pain patients, many of whom have more prolonged and higher dose requirements than the average population! You can imagine how the treatment of a fellow physician under such pretexts sent shivers of worry through our medical community.
The net result is that, as doctors, we don’t like prescribing narcotics. As soon as feasible—sometimes way too prematurely—we try to substitute NSAIDs. We want our orders and prescriptions for narcotic medications to be seen as extremely conservative and well within the bounds of usual and customary practice. I contend, however, that since almost all patients are under-medicated with analgesics (medicines that relieve pain), we have arbitrarily and erroneously set the bar too low. I suspect that this trend will continue as long as the government continues to indiscriminately frown on all narcotic usage. Federal authorities, such as DEA, are fixated on squashing drug abuse in all its forms. Naturally, physicians and pharmacies are the easiest targets, since most illicit drug dealers don’t prescribe medicine through computerized records.
I believe that relief of pain and suffering is one of the fundamental responsibilities of a doctor, and especially a surgeon, who must knowingly inflict pain on patients through the performance of operative procedures. It’s a pity political agendas have so befouled the waters that we cannot see our way clear, as doctors, to ensure that our patients are as pain-free as possible.
Let me close with a couple of comments about drug addiction. Yes, anyone can be addicted to narcotics. Exactly how and why some people become severe addicts and others do not is not completely understood at present. It appears that some individuals possess brains whose neuro-chemical structure makes them incredibly susceptible to addiction of all kinds, not just narcotics. Other people’s brains are not prone to become addicted. Doctors don’t want to turn folks (including themselves) into drug addicts. This means that narcotics need to be vigilantly administered and their use tightly controlled, but it does not mean that opiate medication should never be prescribed.
While addiction to narcotics is a big problem, there are patients who must use opiates on a regular basis to remain active. If they do not receive medication of some kind, they become restricted by severe pain. These are the toughest patients to treat because they have legitimate need of narcotics as well as a tendency to become dose-tolerant if they use the drug too long or too frequently.
As a neurosurgeon, I’m also well aware that there is now a plethora of surgical procedures to alleviate pain. These operations include intra-thecal pumps, indwelling dorsal column stimulators, direct nerve stimulation and even outright destruction of nerve and brain tissues. Many of these operations, in my opinion, have dismal success rates. Of course, there are patients who benefit from such extreme interventions, but for most chronic pain sufferers, narcotics achieve better, reliable results. So we need to make sound judgments about offering surgical intervention as an alternative to administering and monitoring narcotics.
There is also a sinister side to surgical procedures for pain relief: unsuccessful procedures only increase the formation of scar tissue, increasing the sources of pain that need to be suppressed. One reason there is such a profusion of procedures to offer patients with chronic pain is that there is no consensus as to which ones are effective. New approaches, techniques, and hardware are incessantly appearing on the market, touted as the next panacea for pain. So far, it has not materialized.
There’s one group where withholding opiate medication because of concerns about addiction makes no sense at all: terminal cancer patients. I see doctors, even oncologists, dole out doses of narcotics parsimoniously. Stingy notions about pain medication often leave the terminal patient in unrelenting agony because of irrelevant concerns over eventual addiction. If someone is dying of cancer, do we really care if they become addicted to pain medication? Isn’t death going to bring an end to the requirement for opiates? The reason I harp on this is because so many cancer patients are left in mind-numbing pain that destroys the quality of whatever time they have left. That’s frankly unconscionable when we have so many narcotics with which we can alleviate suffering.
No comments:
Post a Comment