Wednesday, July 20, 2011

MORE ON CHRONIC PAIN

struck a nerve, so to speak. There are now over a hundred comments on it, and several here on this blog, consistently stressing two points, drugs and subjectivity. My thanks go out to all commenters.

Drugs--especially opiates, or narcotics--are, in the short run, a miracle and a blessing. When I was an ER doc, one of my most satisfying experiences was to inject a bolus of morphine into the vein of someone writhing on the table from a kidney stone. I'd say, "Count to ten." By seven, they'd sigh and smile.

Take opiates for awhile, though, and problems can appear, and not necessarily addiction. Sometimes we'd keep hospitalized patients on opiates for a couple of weeks, sending them home with a diminishing dose. I never saw a single one become addicted, though I recognize some people with a craving personality do get hooked. A more common problem is side effects, including agonizing constipation, lethargy, and even disorientation. Considering that we develop tolerance to opiates, chronic users will require progressively higher doses and suffer proportionate side effects. In addition, the feds do indeed maintain a regressive attitude toward opiates, reflected in the fearful reluctance of many docs to prescribe them at all. (I've mentioned elsewhere in this blog the usefulness of that phrase that knocks around in cancer support circles, "No one should be allowed to treat a disease they haven't had themselves.")

The other theme in all these comments is subjectivity. Some policies limit opiate prescriptions to cancer patients, since, evidently, they're not faking. Cancer is objectively real, and everyone knows it can hurt. For those patients who don't have verifiable pathology, though, who knows whether their pain is "real" or not? So it is that many people are slog through their lives today treating their severe pain with Tylenol.

This brings to mind the previous blog entry, about prospective medical students being screened for communication skills (http://well.blogs.nytimes.com/2011/07/10/screening-for-a-better-medical-student/). A proficient communicator--that is, someone who listens fully and speaks truly--is therapeutic, period. When people know their suffering narratives have been heard, they feel better. Beyond that, being heard begins to help them live with their symptoms rather than devote their lives to avoiding them. Of course, this level of practical compassion isn't achieved through med school application interviews. It needs to be a perennial element of medical training.

5 comments:

  1. Hello Dr.Jeff Cane: came to your site from the N.Y.T. article. Liveed in Nevada City (64 acres out on Cement Hill Road/old "Painted Lady on Park Ave.)Also know a Dr. there, a Cancer radiologist, name is "David" Somebody. I am collecting articles, blogs, etc. for a new web site I am creating called: "So this is getting OLD....". I am 75....ans Really like your blog.
    "And the Beat Goes On" (http://andthebeatgoeson-2007.blogspot.com/)

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  2. I also followed you here from the NYT, sort of hoping against hope that you were within a state or two of me. No such luck.

    I have chronic pain and my doctor of two decades recently retired. After a year searching for a new doctor, I have given up completely. (Try this, call a dozen Drs, tell them you are potential new patient with migraines. Listen to the reasons they can't take you.)

    I have seen half a dozen doctors. Once each. This means I have paid about a thousand dollars for the privilege of being rejected by the people whose job it is to help me. My favorite was someone who, after my two and a half hour drive, looked at my intake sheet and sniffed, "I don't like to treat people in pain." I looked quizzical and she explained, "I mean, I don't take new patients who are in pain. It's such a hassle." (Excuse me, I don't exactly LIKE being in pain. What the hell? Is this not your JOB?)

    The last person who was willing to see me recommended 4 surgeries before she read my chart or did a physical exam and then insisted I take a criminal drug test, even though I said I didn't want pain relief medication (since that seems to be the stumbling block). I declined on civil liberty grounds and was told every patient is required to pee in the bottle - and PAY for it - then escorted out. Policy trumps health care, I guess.

    This has left me with daily pain of 3-7 and other untreated life-threatening health conditions. (Several hospital stays in last 18 months for intractable vomiting / dehydration) I have told a couple of critical people that I would rather die than set foot into another medical establishment and I mean it.

    So there you have the state of health care, from one patient who is so afraid of the system that I am unwilling to even give you my email address.

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  3. I have trigeminal neuralgia. It is the result of a birth defect (a partial Sturge-Weber). Despite my having visible manifestations of it (a vascularized birthmark covering the area of the pain (v1, v2 (L)) I still had doctors, as well as family members question the validity of my pain.
    I have been on narcotic meds for years. This may be only anecdotal but I have never had to go up to higher and higher doses.
    I appreciate that you mentioned not seeing one person addicted. This is one of the worse lies, that repeated and repeated is being believed by the populace as well as government, that chornic pain patients become addicted as a rule, rather than as the exception.
    I have had both good and bad communicators. The bad ones cause me to be a bad communicator in return. The good ones hear me and listen to my words, hear the truth of the pain so I do not end up having to defend it.
    Thank you for this article.
    My book, A PAINED LIFE, a chronic pain journey, tells of my experience as a person with trigeminal neuralgia (tn), a severe and often disabling facial pain disorder.
    My tn is the result of a birth defect, proven by surgery and visible manifestations. Nevertheless I still had doctors question whether my pain was "real" or 'as bad as you say it is'.
    Pain is only one of many 'invivible' illnesses yet most you don't have to prove, only pain, and yet how do you prove you have pain? It often puts us in a no win situation, complain loudly and you are 'putting on a show', complain softly and 'it must not be that bad'.
    The Bachman issue of her migraines brings up another issue.
    Research has shown there continues to be gender bias in the medical community against women who present with pain as a main or sole sympton despite the fact that women have higher incidences of those disorders with pain as the main or sole complaint: MS, lupur, CRSP, trigeminal neuralgia, rheumatoid arthritis, etc.
    Chronic pain is a societal issue, in terms of equal treatment of the sexes as well as money and lives lost to pain.

    Carol Jay Levy
    author A PAINED LIFE, a chronic pain journey
    http://womeninpainawareness.ning.com/
    http://apainedlife.blogspot.com/

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  4. I noticed I left off a critical bit - I won't go to a US medical facility. Medical tourism is looking interesting, however.

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  5. Through extensive training I have become completely objective in my subjectivity.

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