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8 Articles in Volume 5, Issue #2
Considerations in Treating Intractable Pain
Hospice Care Evolution
Myofascial Elements of Low Back Pain
Radiofrequency Neuroablation in Chronic Low Back Pain
State Pain Laws: A Case for Intractable Pain Centers Part III
Temporomandibular Joint Referred Pain
The ABC’s of Pain
Therapies for Chronic Pain and Fibromyalgia

Considerations in Treating Intractable Pain

Intractable Pain (IP) patients not only present unique factors that differentiate them from other patient groups, but also each individual’s background, personality, coping skills, etc. requires additional adaptation.

By the nature of their condition, intractable pain patients, as a group, are not like any other patients. The essential difference about pain is that it is compelling beyond all other symptoms. A patient may live with loss of appetite, weakness, shortness of breath, visual changes, lack of coordination, and virtually every other symptom with relative tolerance. But pain is absolutely imperative. The common suggestion by doctors that a “patient should learn to live with their pain” is a bizarre conundrum. It reveals the speaker’s ignorance on the subject, as any human being who has ever been in severe pain knows that this is a ridiculous suggestion. It would be comparable to a heart surgeon telling a patient with mitral valve prolapse to “learn to live with it.” To belabor the point, another example would be to tell a patient with an ice pick stuck in his brain to “learn to live with it,” because the doctor was afraid to remove it. One should never tell a pain patient to learn to live with their pain. It will irreversibly establish the speaker as an incompetent and/or sadist in the mind of the pain patient.

Understanding Personality Types

To fully understand the presentation of a pain patient requires understanding personality types. Predictably, patients’ responses to pain vary in relation to their character structures. A person with an hysterical personality pattern, for example, will respond to pain hysterically. Similarly, an obsessive-compulsive patient will be obsessive about their pain, frequently coming to the doctor with detailed descriptions and notations on their symptoms. More importantly, if a patient has a dual diagnosis, for example if they also suffer from a bipolar affective disorder, they may vary dramatically in their behavior toward their pain. On one visit they may be controlled and phlegmatic; on the next visit they may be chaotic and desperate. The pain has not changed, but they have. Frequently these variations are misinterpreted by the physician to imply that the patient is faking the pain, since the responses are so inconsistent. Beware of hasty generalizations.

As another example, a sociopathic personality will approach their physician very differently from the approach of a religious conservative. The religious person may come in with a deep despairing depression, having interpreted their suffering as a personal punishment from God. The sociopath, however, having no capacity for human trust, will feel it is impossible to relate directly and honestly to the doctor. Not believing in compassion and not able to experience it within themselves, they will not believe that the doctor can be trusted to be compassionate. So, invariably they will believe that their needs can only be met through manipulation and duplicity. Their behavior does not mean that they are not in real pain. It only means that they are structurally crippled in their ability to relate directly and with trust. But even sociopaths have real pain.

“Intractable pain patients present with the most daunting, complex and frustrating conditions a physician will ever have to confront. Intractable pain patients rarely get entirely well; with effective care they can be stabilized sufficiently to have some quality to their life.”

The essential fact is that the competent physician must have his or her mind and eyes open for all aspects of the patient and all diagnoses. Stereotyping is as undoing in the successful treatment of pain as in every other medical condition. For example, just because young women rarely have heart attacks doesn’t mean that a young female patient with crushing chest pain shouldn’t have an EKG. Blind obedience to stereotyping is the handmaiden of medical malpractice; most particularly in the management of intractable pain. Just because a sociopath is manipulative, duplicitous, and conniving, doesn’t mean that they are not genuinely suffering from pain and have an absolute right to treatment and relief. It only means that the doctor must be wise enough to understand the whole patient and perceptive enough to see beyond stereotypes.

Unique Nature of Intractable Pain

Intractable pain patients present with the most daunting, complex and frustrating conditions a physician will ever have to confront. Intractable pain patients rarely get entirely well; with effective care they can be stabilized sufficiently to have some quality to their life. Intractable pain patients have, by definition, an intractable condition. They will require ongoing prescriptions of various narcotic pain medications. This will create problems with opiophobic pharmacists, other practitioners, and in some states without Intractable Pain Acts, possibly even review and regulatory harassment by medical boards or boards of pharmacy.

Unless the physician is adequately trained to be expert in the use of opioids — particularly sustained release preparations — and professionally committed to proper intractable pain management, he or she should simply refer these patients to someone who is. Otherwise the inevitable result will be frustration, anger, suspiciousness, and alienation between the doctor and the patient. Typically, doctors will unconsciously vent their frustration by “blaming” the patient for not getting well, or by accusing them of being addicted to narcotics (true pain patients virtually never suffer physiological withdrawal from opioids, but they do suffer withdrawal from the relief of their pain). Also doctors frequently displace their own fear of regulatory harassment — or doubt about their own effectiveness — into resentment of the patient.

One of the most common occurrences is the labeling of patients as “drug-seeking.” This is commonly used as a basis upon which to ignore or deny effective relief to the patient. The reality is that patients rarely are seeking drugs. In fact, they are seeking relief. There is a categorical difference. The point is that unless the physician can consciously deal with all these complications, they should refer the case rather than succumb to inadequate medical practice.

Iatrogenic Complications

Treatment of intractable pain may be fraught with numerous iatrogenic complications — chief among them being inadequate treatment. Treatment is inadequate if insufficient medication or if the wrong medication is prescribed, as described below.

Insufficient Medication

If the proper opioid is chosen — but provided in inadequate doses — intensification of the pain occurs from rebound. The patient is forced into a “roller-coaster” pharmacology. They may yield partial or adequate relief of the pain, followed by a plunge into exacerbated pain every four hours. The current standard of care requires that if immediate release medications are inadequate for effective pain control, then sustained release medications must be provided. In this situation, short-term medications, such as hydrocodone compounds, are appropriate only for break-through pain. The typical prescription for serious intractable pain provides for sustained release OxyContin at a dose sufficient to contain the pain (20,40,60, or more mg) twice or three times daily, with hydrocodone used twice or three times a day for breakthrough pain. If the patient utilizes the hydrocodone more frequently, the dose of the sustained release preparation is too low and should be increased until the patient is comfortable enough that hydrocodone, twice or three times a day at the maximum, is effective.

If containment of the pain cannot be achieved with OxyContin, the sustained release medication should be changed to either MSContin, methadone, or Duragesic in the transdermal formulation. In any case, the principles for treatment remain the same. Short term augmentation with immediate release hydrocodone (or other pain medications such as propoxyphene or acetaminophen), may be necessary. As a general principle, however, the long-acting drugs should be prescribed at a sufficient dose to preclude the need for additional, short-acting, medications.

The recent introduction of sustained release hydromorphone has added another important modality to intractable pain management. Not all patients respond uniformly to various opioids. Some patients do not respond well or cannot tolerate morphine, or oxycodone, or fentanyl, yet do well with hydromorphone. The newly available, sustained-release form of Palladone provides an important new alternative.

Improper Medication

The most common error in the treatment of pain is the substitution of many other classes of medication in an effort to avoid the use of “narcotics.” Most commonly, NSAIDs and COX-II inhibitors are substituted for opioids. This is improper for a variety of reasons. To begin, unless there is an inflammatory component to the etiology of pain, the use of anti-inflammatories is inappropriate. Given the high risk of gastrointestinal irritation and ulceration, there is no justification for their use if no inflammatory condition is present. NSAIDs have caused more than 100,000 hospitalizations and an estimated 16,500 deaths annually, according to the U.S. Department of Health and Human Services posting dated 1/19/2001 (http://certs.hhs.gov/whats_new/archive/2001/20010119_01.html, last viewed 2/24/05). Lastly, the COX-II inhibitors are now known to present significant cardiovascular risks that far exceed the inherent risks of opioids. Fear of regulatory — or even criminal prosecution — is not a legitimate medical reason for substituting these drugs for much safer opioids.

Further, it is an act of bad faith to prescribe an anti-inflammatory while misleading the patient to believe that the medication is an analgesic. It is not. When patients discover that the NSAID is ineffective, and that they have been misled, the therapeutic alliance is irretrievably fractured. If the issue is the avoidance of opioids, it should be addressed directly with the patient. Most patients will accede to a trial of non-opioid medications. If the trial fails, the next step, in good faith, should be the use of opioids as addressed earlier.

The list of drugs prescribed instead of opioids is extensive. Neurostabilizing medications, such as Neurontin, have a role to play when a neurogenic component of the pain is present. Similarly, Trazadone has become a faddish prescription, although the literature lacks any support for the effectiveness of this anti-depressant in relieving pain. The few reports available seem to demonstrate that the relief of depression is useful in the treatment of pain. However, Trazadone, a very old anti-depressant, has many adverse side effects, including anti-cholinergia, a serious risk of lethal over-dosage, and commonly causes weight gain. All these adverse complications can be avoided by using modern anti-depressants. Further, the newer antidepressants are substantially more effective in relieving depression than Trazadone. This places the use of Trazadone as a first line antidepressant on dubious ethical grounds.

With intractable pain, trying to avoid prescribing an opioid is not a justification for prescribing potentially far more dangerous and toxic substances such as NSAIDs. In summary, the risk-benefit ratio must determine which medication is chosen for any clinical condition.

A Case History

The patient is a 37 year old refrigeration technician for a national corporation who suffered a fall at work three years previously. He never recovered from the fall and developed a radiculopathy which eventually led to laminectomy and fusion of L45 and S1. The surgery did not relieve his pain and the patient was never able to return to work.

The patient was referred for intensive in-patient evaluation and physical therapy by his wife. The patient was transferred from an in-patient facility in Florida where he had undergone detoxification from hydrocodone. He had been taking 18 to 20 Lorcet (hydrocodone/Acetaminophen) daily in an effort to contain his pain. At the time of transfer he was receiving intramuscular buphrenol twice or three times daily, Trazadone at bedtime and vistaril 1mg i.m., two or three times daily.

At the time of initial evaluation the patient was severely depressed. He stated definitively that if he was not able to get a lasting relief from his pain that he wanted to shoot himself in the head. Because of recurrent suicidal urges he had gotten rid of all the firearms in his home. He had suffered on-going insomnia for many months. He explained that the pain frequently awoke him at night, and that he rarely was able to sleep for more than a few hours at a time. He walked with a cane as he was quite unstable. His mood was moderately to severely depressed. His affect was appropriate. He related comfortably with the interviewer and maintained good eye contact. His speech was clear and cogent, and he reached goal ideas with facility. There were no delusions or other primary psychopathology present. His memory was intact in both immediate recall and long-term. His intelligence was above average, as was his fund of knowledge. He was a credible informant and elicited empathy. Physical examination revealed a disabled person with extreme limitations of mobility. In the standing bend he was unable to come closer than 24 inches to the floor with both hands. His flexibility from the sitting position was comparably restricted. His strength was reduced for his age and occupation.

The patient was admitted for a comprehensive treatment in a hospital for comprehensive, in-patient physical rehabilitation. Members of the team included a board-certified physiatrist, the author of this report, a psychiatrist with 15 years of experience in the treatment of intractable pain patients, and a psychologist who is a fellow of the American Association of Pain Management.

“At the end of the first week of treatment, including pharmacotherapy, massage, stretching, endurance exercises, heated pool work, the patient was extremely satisfied with his progress. In the weekly team conference, all departments reported excellent progress.”

Following the initial work-up, the patient was started on a program of pain containment, utilizing Fentanyl patches. Parenteral Buphrenol and Vistaril were discontinued. The 50 microgram size patch did not initially control the pain. When the patient complained and sought more medication, several members of the nursing team reacted negatively to his requests, treating him “like an addict,” he reported. He considered leaving the hospital against medical advice. The senior member of the treatment team was contacted by the patient’s wife.

He conferred with the treating physiatrist and psychologist. All agreed that only the senior physician would write pain management orders for the patient. This physician then explained to the patient that the first priority in his treatment was finding an analgesic regimen that adequately controlled the pain. He informed the patient that he would add Lorcet 10 on a twice daily basis to cover him for breakthrough pain. Further, when the next Duragesic patch was to be applied, the dose would be increased to 75 mcgm/hr, to provide greater control over the pain. Further, he informed him that this was a decision reached concurrently by the treatment team. The patient calmed down and promised to give treatment a chance.

At the end of the first week of treatment, including pharmacotherapy, massage, stretching, endurance exercises, heated pool work, the patient was extremely satisfied with his progress. In the weekly team conference, all departments reported excellent progress. The patient’s range of motion had increased more than 12 inches on the standing and sitting bends. His pain level had dropped dramatically. EMG revealed, however, significant radicular irritation at the level of his lumbar fusions. Referral for orthopedic consultation was scheduled at the local medical school with the professor of spinal surgery, to assess his condition and determine if any surgical intervention might offer him relief. The patient adamantly stated that he would not undergo another surgery, as the first had left him so crippled and in such severe pain. After considerable discussion he agreed to accept the consultation and to maintain an open mind about possible future surgery. He accepted the point that “the baby should not be thrown out with the bath water,” i.e., that because the first surgery had not been successful did not mean that no surgery could help. The nursing staff, with explanation, no longer viewed him as “medication-seeking,” and now took pride in the patient’s progress in treatment.

It is very probable that the patient will remain on a pain-control regimen for the rest of his life if surgical intervention cannot relieve the cause of his radicular irritation. He accepts this, but has already begun planning to begin looking for an alternative vocation. He reports that he can now imagine doing “something productive again,” for the first time since his injury. His mood is definitely improved, and he reports that he has been able to sleep through the night with the help of the patches. He is enormously relieved by this change alone. He also appears to be demonstrating an early response to the antidepressant which he has been prescribed. His wife reports that both are now very satisfied with his treatment and progress.

This case illustrates the principles of treatment discussed previously. With careful attention to the principles, one can accomplish — with virtually any chronic pain case, regardless of etiology — the following:

  1. Sufficient control of the pain to permit rehabilitation.
  2. Avoidance of “medication-seeking” behavior.
  3. Avoidance of depression and suicidal risk.
  4. Reliable and consistent improvement in range of motion, personal function and recovery of ordinary activities of daily living.
  5. Avoidance of stereotyping of the patient as an “addict.”
  6. Avoidance of inappropriate, dangerous and ineffective medications.
  7. Avoidance of staff and physician frustration and therapeutic failure.

Conclusion

With proper treatment of intractable pain, medical care can become a “win-win” situation for all involved. Regarding the issue of opioid “addiction,” the work of Sorensen and others (www.medsch.wisc.edu/painpolicy) has demonstrated beyond any reasonable doubt that intractable pain patients do not become pathologically addicted to opioids, when they are prescribed within the context of a comprehensive and consistent treatment. Indeed, the vast majority of pain patients strongly dislike having to use medications, and universally cease the use of all drugs in any instance in which the cause of their pain is eliminated. At this point, it is the position of the National Foundation for the Treatment of Pain (www.paincare.org) that opioid addiction is entirely an iatrogenic complication of inadequate and inappropriate medical treatment.

Last updated on: January 28, 2012
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