Share the pain!
July 1, 2006 10:32 PM   Subscribe

"Doctor, it hurts when I do that." Doctors and patients agree - doctors are lousy when it comes to recognizing, diagnosing and treating pain. The AMA developed this free Continuing Medical Education tool (requires Flash) to help docs learn and understand how to deal with pain - but other folks, folks who are now in pain or might someday be in pain, might find it quite interesting as well. All docs in California have to complete this seminar or a similar one by the end of 2006 to get relicensed; the hope is that this will help the docs and the patients who have to deal with pain on a daily basis.
posted by ikkyu2 (24 comments total) 4 users marked this as a favorite
The problem with pain is that it's not something that can be measured objectively. There is no pain detector that can be used to assess pain. It's all based on the reports of the patients. The management of pain is then based on physcians fear of DEA or state assessment of their prescribing habits. The level of scrutiny placed on prescription of narcotics is probably the greatest deterent to actual pain management in medical practice. But what do I know? I'm just a doctor.
posted by shagoth at 10:36 PM on July 1, 2006

I wish every doc had to do this, not just the ones in Cali. Chronic pain sucks, and it is a condition unto itself, and it's hard to find a doctor that understands, sympathizes and has the knowledge to find solutions to treat chronic pain.
posted by exlotuseater at 10:39 PM on July 1, 2006

But what do I know? I'm just a doctor.

Yeah, me too.

Did you even look at the link? There is an entire section apiece devoted to each issue you raise in your first, second, third and fourth sentences.
posted by ikkyu2 at 11:01 PM on July 1, 2006

I'm Dr. Feelgood. I'm the one that'll make you feel all right.
posted by papakwanz at 11:06 PM on July 1, 2006

Pain Relief Network
posted by homunculus at 11:13 PM on July 1, 2006

This is a problem that started during the Nixon administration. See, there's a really cheap, effective, easy answer to most of the kind of pain that's undertreated in the US: morphine. It works really well.

And any doctor who is suspected of overprescribing it can lose his license to practice medicine, and can even land in prison. Who judges it? Well, the Drug Enforcement Administration does.

As a result, doctors have for a long time now been extremely conservative about treating pain, using far less morphine than they really should. The FDA has in fact issued rather emphatic pronouncements that doctors should be using more morphine. But doctors would rather anger the FDA (who can't do anything) instead of the DEA (who can prosecute).

There may be few kinds of major injury that cause more pain than burns. One step in the process of treating burns is called "debriding"; it means that all the dead tissue has to be removed. The patient is put in warm water, and then the burned area has to be scrubbed in order to break free all the dead tissue.

It hurts more than you can possibly believe, because these days it's done without any anesthetic. Which is really stupid. Every one of those patients should be doped to the ears on morphine before it begins; there's no good reason at all to make people suffer like that.

But because the DEA is always sniffing around looking for excessive and unwarranted use of class 1 narcotics, doctors routinely undertreat this kind of pain, just as they do nearly all others.

My dad died of pancreal cancer in 1972. Fortunately, that was before the clampdown, and once it was clear that his cancer was terminal, his doctors told him that he could have as much demerol (synthetic morphine) as he needed to stay out of pain. Down to the end he was taking a regular dose which would kill you or me; but what difference did it really make that he was by that point addicted to the stuff? None.

If he had died five years later, he would have left us screaming in agony instead of sleeping most of the time and being out of pain the rest of it.
posted by Steven C. Den Beste at 11:17 PM on July 1, 2006 [2 favorites]

Thank you ikkyu2 for bringing this to the attention of non-medical people like me. It certainly seems like a step toward having doctors in charge of treatment instead of politicians.
Next step: reduce the interference of insurance companies.
posted by Cranberry at 11:48 PM on July 1, 2006

Thanks for the link.

The DEA harassed my mother's pain doctor until they managed to get his license suspended for a year. He had to declare bankruptcy and sell his practice. His patients were left in the lurch, many of them on pretty high levels of opiate use, suddenly out of luck and left to try to find a new doctor within a few weeks or try to convince their GP to renew their prescriptions... When so many of their GPs were too uncomfortable prescribing such high amounts of opiates, which is why they sent their patients to the pain doc in the first place. In my mom's experience, most GPs freak out over prescribing 30 tylenol #3's a month.

It was the medical board that suspended the doctor's license, and no followup checks were ever made to see how all of his patients were doing afterwards (or at least they didn't include my mother or the people she's talked to in the waiting room since). Some of his colleagues actually came out of retirement to get the practice functioning again, they contacted the patients to inform them that they were back in operation 4 or 5 months after the practice closed. The practice has new owners, who are not doctors, and every aspect of policy in the practice is reviewed closely by lawyers. According to the new pain doc at the practice, the old pain doc prescribed too many fentanyl lollipops, which is a red flag to the DEA and made him a target.

I guess my point is that even a thorougly knowledgeable extremely competent and compassionate pain specialist (and lord knows there are so few of them) cannot do much good in the current political climate. I'm afraid we either need the medical community to band together and push back politically, or get a mass social movement going. I hope the California state license requirements are a sign of that starting to happen.
posted by overanxious ducksqueezer at 1:18 AM on July 2, 2006

Yeah, I know. The same quarterly issue of the Medical Action newsletter from the California Medical Board that recommended 10 programs for AB 487 compliance (none of which were free, unlike the one I linked) listed 6 physicians whose licenses were revoked due to inappropriate prescribing of narcotics. The message to physicians is terribly mixed.
posted by ikkyu2 at 1:50 AM on July 2, 2006

Patients in hospice, or in hospital with clearly terminal conditions are often allowed greater opiate dosages. My father, dying of lung cancer, fighting for each breath, was allowed morphine and ativan "as needed" at the end, and his floor nurses made sure he was getting all he needed, even to the point of clearly depressing his failing breathing. My mother, who had died 6 weeks before of diabetic complications that included pressure sores and tissue breakdown over her pelvic pressure points that exposed bone tissue at the base of her spine, was not quite so lucky. She definitely could have used more morphine, but was made to do without because until her final 48 hours of congestive heart failure, she wasn't "terminal"...
posted by paulsc at 2:13 AM on July 2, 2006

"Doctor, it hurts when I do that."

"Well, don't do that, then."

Nice find. Thanks, ikkyu2.
posted by flabdablet at 5:02 AM on July 2, 2006

That Sesame Street bit cracks me up every time I think about it, even 25 years later.
posted by goo at 5:30 AM on July 2, 2006

I have experienced a huge difference in pain management depending on the hospital.

My first back surgery in 2000 was a partial discectomy and, while I got a morphine shot upon initial recovery, the rest of the three days in the hospital was agony. I was watching the clock waiting for the darcovet to come in pill form.

I just had a spinal fusion with a different surgeon and hosptial and was given IV morphine the entire first day then switched to IV dilaudid for the next three days. I was much more comfortable that time around.

Both were with the same insurance company and after both I have been given ample amounts of darvocet (up to 2 every four hours). So, I don't know if the reason for the different treatments were due to the facility, the surgeon or the insurance company.

The doctors I have seen here in California do some pain assessment by moving bits of me around and watching me scream and jump. In a couple of cases, it didn't seem horribly scientific, but since we both agreed I was in pain, we were able to move on to pain management. I do feel like I have been lucky, as I used to run a sciatica forum and heard horror stories of folks with doctors who refused to recognize their conditions due to the fact that it "couldn't be measured." The other stories posted above seem to bear this out as well.

I am glad to see that my doctor will be getting more education on the subject. Thanks for the link, ikkyu2, I will definately spend some time with it and recommend it to others.
posted by sciatica at 6:06 AM on July 2, 2006

Not to rain on anyone's parade, but I have had situations where both my parents received what I believe to be TOO MUCH pain medication that had a variety of bizzare and dangerous effects. In my father's case he was hospitalized for a couple of months in severe pain , drugged with some kind of patch he wore, and became delusional, insisting that they were killing patients in the next room, and that the news was playing repeats from a few years prior... He was like that for days before we convinced the docs to take the patch away. (Sorry I can't recall what it was), and he said he wasn't in such pain afterwards that he didn't need anything more than tylenol. Me Mum broke a hip and was on Morphine. She started acting like the local crazy lady, swearing, and insisting that she was elsewhere, and that the nurses were trying to kill her. A lower dose cured her of that. She didn't complain of pain either.
posted by Gungho at 7:14 AM on July 2, 2006

In Gungho's case its probabaly a fentanyl patch. It can cause that type of side effect so it should have been removed and another pain medication tried.
Things in the UK a bit different. Pain therapy is a sub-specialty of Anaesthetics, and it's quiet recent. Up until then most patients went to their local GP, some of whom were single-handed practices, like the infamous Dr Harold Shipman. As a result of his use of morphine with patients who were frequently not dying, the whole tenor of pain prescribing is changing to what you guys are describing above.
Hope Mr Wilder jumps in on this one soon, he's a pain therapist, but has his own identity on Metafiler (the name of which he won't tell me, GRRR!)
posted by Wilder at 8:39 AM on July 2, 2006

Doctor [palpating leg]: Does this hurt?
Patient: That's your leg.
Doctor: Yes. Yes, it is, isn't it?
posted by nylon at 9:23 AM on July 2, 2006

Thanks, ikkyu2. I'm really glad to see a doctor concerned about providing adequate pain care; I've never been in chronic pain and I hope I never will be, but I've heard enough horror stories about DEA prosecutions of doctors to worry that even the doctors who do see it as a serious problem will start to think it's not worth it for them to treat.
posted by transona5 at 10:06 AM on July 2, 2006

See, there's a really cheap, effective, easy answer to most of the kind of pain that's undertreated in the US: morphine. It works really well.

I had surgery last week and as I came out of the anesthesia, I was swearing in pain, they gave me Toradol first. For some reason Toradol just doesn't touch severe pain in me, even though it does help others. A few minutes later, when the nurse realized I was still in great pain, he gave me morphine.

The pain melted away and I could get control of my breathing then and relax some. I'm lucky that they gave me that as I have had surgery in the past that they did not give me adequate pain relief, which extended the recovery time.

I'm also a chronic pain sufferer. No doctor will prescribe proper pain medication to help me, so I spend everyday of my life in pain. And, it's solely due to fear of losing their license, as several doctors have told me. It's horrendous that I have to spend my life like this due to people at the DEA.

I wish I could take the legislators and the people at that agency and force them into severe pain for a long period of time. Then tell them they can't have what would help them, as it might draw too much attention to their doctor.

I'm glad to see that California doctors are going through this education but, if the DEA keeps enforcing things they way they do, we may have more educated doctors who just realize how tied their hands are.
posted by SuzySmith at 1:39 PM on July 2, 2006

The nonpharmacological options did not menion hypnosis specifically or I may have missed it. Is there a state-of-the-art pain management hypnosis textbook? The best I have seen is Ernest Rossi's stuff from around twenty years ago and his most recent efforts seem to be almost in castaneda la-la land.

If you have not read the thing about Dr. Erickson and the talk about growing tomato plants with the terminal cancer patient at the beginning of "patterns for the hypnotic techniques of milton erickson" by Bandler & Grinder it is definitely worth a look.
posted by bukvich at 6:59 PM on July 2, 2006

Hypnotic pain relief is of a piece with the placebo effect and acupuncture. Now that we've discovered endorphins, we know that there's a real physiological process behind it and it isn't "all in the mind". But what we also know is that no one has found a way to routinely and reliably stimulate release of endorphins.

In other words, hypnosis isn't the answer. Not yet. It works for some people, some of the time, somewhat. That's not good enough.
posted by Steven C. Den Beste at 7:04 PM on July 2, 2006

[repeatedly stabbing self in the eye] "Doctor, it hurts when I do that."
posted by nlindstrom at 10:17 AM on July 3, 2006

Just thought I'd update anyone interested in chronic pain and pain specialists. Talked to my mom yesterday on the phone, she'd had her pain doc appt a few days before. The nurse practitioner told her that the DEA is going through their patient files looking for a "big fish." They want to bust a patient. The nurse practitioner was telling her she wishes they'd look somewhere else. I'm astonished because the previous pain doc is gone- he was a "target" of the DEA so I understood that they'd got court permission to go through his files whenever they wanted and it went on for years. But this must mean they got another subpoena for the practice, or got it extended to the practice even though he's not associated with it anymore. It really infuriates me that doctor-patient confidentiality does not apply to pain patients anymore.

And the DEA's M.O. seems to be to try to bust patients and former patients so they can turn the patients against the doctors. I'm pretty pissed off and I thought other people should know what's going on.
posted by overanxious ducksqueezer at 6:24 PM on July 5, 2006

Six pills. Twenty-Five Years.
posted by homunculus at 1:18 PM on July 8, 2006

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