Chronic Persistent Pain Can Kill
Having been a physician for over 30 years, I have treated literally thousands of patients of all ages who have come from virtually all walks of life. As a solo private practitioner for over 25 years, specializing in rheumatology and pain management, I see first hand the impact chronic pain can have not only on the patients’ health but also on the quality of their lives, especially when it comes to interpersonal relationships and finances. Chronic pain can be a significant stressor per se and its sequelae can often include divorce, social isolation, and financial ruin.
At the twelfth annual American Academy of Pain Management meeting, I lectured on the topic of chronic pain shortening life. It was entitled, “Can Pain Kill?”1 I emphasized that chronic pain is a significant source of stress and that stress can cause problems with a patient’s immune system which, in turn, may lead to increased risks of infection, cancer and other medical problems. Having been trained as an immunologist whose PhD thesis dealt with B-cell and T-cell cooperation, I naturally approached the subject of chronic pain from an immunological perspective. More recently, authors have described deliterious effects of chronic pain affecting other organ systems.2,3 Moreover, abrupt discontinuation of opioid medication can result in potentially lethal cardiac problems such as a Takotsubo-like cardiomyopathy.4 This case report focuses on the untimely death of a relatively young adult due, in part, to chronic persistent pain. It was first described by me in 2005.5 Since that time, other such cases have come to the fore.
A 39 year-old white male was referred to my office by his attorney for an evaluation of injuries he sustained while working on a barge. He was employed as a tankerman with an oil company and was dispatched to load a barge with gasoline. While doing so, a chicksan (an apparatus used to transfer fuel from storage tanks to barge) malfunctioned and struck the patient on the chest, left shoulder, abdomen, left leg/ankle, and right leg/ankle. He was driven into the mooring cell and became trapped. He had chemical/gasoline burns on his feet and suffered injuries from being crushed between the loading arm of the chicksan, barge, and the dock’s mooring wall. He was taken by ambulance to a hospital where he was admitted to the trauma service. On the way to the hospital he was noted to be hypotensive with a blood pressure of 90/P. He was given intravenous fluids which raised his blood pressure to 110/P. He was discharged from the hospital with a diagnosis of:
- right bimalleolar ankle fracture,
- left ankle sprain,
- left dorsal foot abrasion,
He was treated with Warfarin Sodium (Coumadin®) for prophylaxis against thrombosis, 1800 calorie ADA diet, closed reduction and splinting of the right foot and ankle, and immediate release Oxycodone/Acetaminophen (Percocet®) for pain. He was seen by several consults and was transferred to a Rehab Hospital where he remained for 8 days. The patient told me that while he was in the hospital he rarely slept because he was in a lot of pain and often was up while the other patients were sleeping. He became quite anxious and was very upset at the fact that he could not work and was in a great deal of pain. He was discharged from the hospital on tapering doses of slow release Oxycodone (Oxycontin®), Gabapentin (Neurontin®) 300 mg bid for neuritic type pain, oral hypoglycemics for noninsulin dependent diabetes, Warfarin sodium, enalaprilat (Vasotec®) for hypertension and other medications. He developed acute cellulitis of the right foot and was readmitted to the hospital 13 days after initial discharge where he remained for 3 more days. He was treated with intravenous cephalo-sporin, intravenous Morphine Sulfate, oral Warfarin Sodium. He was discharged on oral cephalexin (Keflex®) and acetaminophen with codeine. The patient told me that this analgesic did not adequately take care of his pain. He was seen at an outpatient rehab facility for three months. Multiple physical therapy modalities were used. The patient told me that he could not tolerate some of the modalities because it caused increased pain while adequate analgesia was never attained. A Work Conditioning Evaluation/Plan of Care was written. In part it stated that the patient had made “...substantial improvement with work conditioning. However he remains limited in tolerance for ambulation distance due to pain and antalgic gait. The patient is also not safe on ladders and presents with only fair balance on level surfaces.”