White knuckles in Recovery Room

His exclamations of pain could be heard through the phone line as the RN gave me the consultation request.  He was post-operative from a knee surgery and was waking from general anesthesia with severe pain.  He had a history of long term opiate use at high doses for chronic back pain.  The recovery room nurses could not get control of his pain.  Fortunately, my office was across the street and I was able to respond quickly. 

On my arrival, he was gripping both rails of the gurney so hard that all the blood had drained from his hands.  Under my guidance, the RN started infusing repeated doses of a strong opiate called Dilaudid.   His blood pressure was high, his heart rate was fast and his breathing was also rapid.  He expressed appreciation for my help, but continued to cry out with pain.  The RN had to keep checking out more ampules of Dilaudid from the locked drawer, finally having to call the pharmacy for a new supply.  It took an hour of focused care and very active infusion of this strong medication to finally gain control of pain.  Only then did he release the side rails and the color returned to his hands.  Before we were through, he had received the highest amount of Dilaudid I had given to someone in one setting in my career.  Giving large amounts of opiate always carries the risk of breathing problems, but he had no sign of suppression of his breathing or of decreased alertness.

This is Tolerance.  It is not our friend.  Long term exposure to opiates, as well as alcohol use and some other medications can lead to this.  It will take higher and higher doses of opiates to achieve the same effect in a person with tolerance.  Sometimes a patient will express that a dose of medicine was “just like water.”  Typically, this is due to tolerance.  The medication will not particularly have an effect until given at a much higher dose.  Unfortunately, the medical care givers will often view such a person as “drug seeking.”  There is no test to rule that out, so personal prejudices often rule the day as to what treatment will be given.  This applies to both nurses and doctors.  Some nurses view it as a victory to end the shift, having given less pain medicine to the “needy” patient.  Physicians are also challenged with biases.  The emergency room is especially plagued with people with multitudes of pain complaints.  Sorting out ”legitimate” ones from the others is part art and part science and training.  Unfortunately, if the required dose is high, the person will ultimately be judged a “drug seeker” in many cases.  Physicians in this setting often become jaded due to the high volume of those with addiction problems.

How wonderful it would be if we could somehow block tolerance from developing.  So far, we cannot.  This means that medication at the usual doses is sometimes like spitting in the ocean, with no effect at all.  It is important to know that tolerance to pain medications does not equal addiction to pain medications.  This is commonly misunderstood.  A person can be very tolerant, and yet not be addicted at all.  Addiction is the psychological dependence to the substance and is usually associated with a deterioration of function.  An addicted person will almost universally show tolerance, which leads to suspicion of anyone exhibiting tolerance.

With full knowledge that tolerance is very likely present in those taking opiates long term, one could surmise that advancing the dose over and over would be appropriate to achieve a good effect in the compliant patient who has responded well to this treatment.  Unfortunately, eventually that dose becomes high enough that a physician will become uncomfortable continuing it.  This leads to a referral to a pain specialist, who will also have a maximum dose that he/she is willing to prescribe.  There is no gold standard as to what this maximum dose should be, but it is evolving.  Washington state has written it into law, regulating the maximum amount of various opiates that primary care physicians can prescribe.  The DEA uses accusations of over-prescribing based on total # of pills, when prosecuting physicians.  They have not published what # would be considered acceptable to avoid scrutiny.  In addition to the listed concerns, there are practical concerns such as high cost for high # of pills and logistical issues delivering high # of pills.

Recently, a clinic in the Northwest was raided by the DEA.  Many patients at this clinic were treated with very high doses of opiates.  The apparent philosophy of the clinic was that the sky was the limit for the amounts of opiates prescribed.  The patients from this clinic generally could not find other providers willing to meet this level of prescribing once the clinic was prohibited from further treatment.  High dose prescribing is not sustainable and should be limited to very selective circumstances.

So what is the answer?  To help avoid the scenario described here, we have learned to ensure that patients take their time released pain medications in the AM of a surgery day.  This needs to be with the consent of the surgeon and anesthesiologist, but helps to avoid a marked decrease of this medication in the system right at the point of surgery.  Steps to help minimize tolerance include periodic tapering down or off of opiates if able.  Rotating to different opiates under the direction of a physician may also help.  Utilization of other classes of medication such as antidepressants and anti-seizure medications will help avoid the need to increase opiate doses.

Whoever does invent the pill to stop tolerance will probably win the Nobel Peace Prize.  It would help alleviate the epidemic suffering from all painful conditions.  Someday.

Ed McCluskey, MD

Medical Director

Pain Relief Specialists Northwest

www.prsnw.com

Opiates for Chronic Pain – The good,the bad and the ugly

There was a time in our history that treating even cancer pain with opiates was considered risky.  The Journal of the American Medical Association in 1941  strongly recommended against this practice due to fears of causing addiction.  It has taken many years to liberalize the use of opiates in the treatment of cancer pain.  There have been even more barriers for using these agents  for non-cancer pain treatment.  In the late 80′s and 90′s, there was a trend toward increasingly utilizing opiates long term for non-cancer pain.  The previously held belief that these would always cause addiction was challenged.  The number of specialists treating chronic pain increased during this time as did the number of medications to choose from.  There was a very large study quoted over and over, showing that the rate of addiction was minimal when treating non-cancer pain with opiates.  In retrospect, the study population in no way reflected the chronic pain population receiving chronic opiate therapy.  This study proposed that the risk of addiction was less than 1%, but the evidence was based on the treatment of acute pain, and the study did not extend very long.  On the face of it, the professional community should have questioned how the addiction rate would be less than the expected addiction rate for the population as a whole.

Therapy during this time was often adjusted to try to bring down the pain rating number reported by the patient, 1-10.  Unfortunately, many times this number would not move in spite of significant increases in medication.  This was partly due to the person becoming tolerant to the medication, and partly due to the inherent weakness of self reported numbers to measure pain.  We now focus on functional improvements to help determine appropriateness of medications.  Imagine if we were to have to treat blood pressure problems without being able to directly measure it.  The patient would report that they thought it was high due to pounding in their temples and having a headache.  The physician might respond that they did not think it was high because the patient’s face was not flushed.  The matter is of course settled by the application of a blood pressure cuff and an objective measurement.  Pain is subjective in nature and the experience of pain is incredibly interwoven in the meaning it has for the individual, based on past and present.

We in the medical field often unknowingly train people to use a higher number to rate their pain.  If the patient reports an 8/10, there typically will be a treatment to address this.  If they report 4/10, the practitioner may think that is good and not do anything, whereas the patient is not happy with 4 at all.  The next time, for the same amount of pain, the number will be reported higher.  This is sometimes subconscious, but is certainly understandable.

In the past few years, prescription opiate abuse has markedly increased.  News of Oxycontin abuse, with details of various routes of administration shown in the media contributed to this.  There is a perceived safety by the abuser due to the medications being well defined in their appearance, bearing a stamp on each pill.  As the trend toward more active prescribing for pain occurred, the amount of opiates in the community increased.  Access increased.  Unfortunately, this has led to regulatory concerns that may lead to access problems for those that really need these medications for best control of intractable pain.  The DEA, FDA, and medical specialty societies are working to try to balance the somewhat conflicting goals of control of opiate abuse and the optimal treatment of pain under a physician’s supervision.

An additional problem with opiates has been recently recognized.  When taken long term, they seem to lead to hypersensitivity – hyperalgesia.  For instance, someone could have been treated for a few years for pain related to an ankle fracture that didn’t heal right, and eventually develop total body pain.  Instead of going up on the pain meds, the better therapy would be to go down and maybe off the meds when this occurs.  The problem is that there is no test to determine whether this is what has caused the total body hypersensitivity.

So, what do we do now.  We proceed with caution.  We follow what has evolved as best practice and follow the developments in our specialty closely.

Keys to success:    

1)  A thorough evaluation with a secure diagnosis

2)  Preferably exhaust more conservative measures

3)  Risk stratification for possible substance abuse

4)  Opiate agreement with informed consent

5)  Regular and relatively frequent office visit followups (often monthly)

6)  Urine drug screening to assure compliance

7)  Careful adjustments with reassessment 

8)  Incorporation of other physicians/ team members as indicated.

Through the above, pain specialists are able to use opiates still for non-cancer pain.  They are only a tool, and should be used in the setting of a comprehensive treatment plan that employs other modalities as well.

Ed McCluskey, MD

Pain Relief Specialists Northwest

www.prsnw.com

Crying in Pain, Rash on her Side

Her moans extend into the hallway.  She was curled up on the exam table, crying out that she would rather die than spend another day like this.  Her silvery gray hair reminded me of my grandmother.  Her daughter stood beside her looking at me anxiously.  My heart went out to them both.  “Excruciating pain to the right chest wall, hypersensitive with a rash to the same area.  She cannot bear to wear her bra due to the severe pain when anything touches her skin.”  Shingles!  The chicken pox virus from childhood coming back to play.  It has been living in her nerve roots since she had chicken pox as a kid.  Sometimes triggered by stress or suppression of the immune system, this is one of the most painful conditions we can suffer as humans.

Her primary care had prescribed anti-viral medication and Vicodin, but her pain did not respond to this.  Nerve pain from various causes often does not respond to typical pain pills such as Vicodin.  I discussed this with them and suggested initiating seizure medication.  This class of medications is effective through suppression of some of the electrical hyper firing of nerve fibers.  We scheduled her urgently for an epidural injection with numbing medication.  As I had seen before,  this injection lowered her pain by 50%.  She was so thankful.  I could see the peaceful relief come across her face as the medication soaked into the nerves.  We repeated the injections a couple more times over the next few weeks, with incremental improvement that was sustained.

At the last appointment, she had driven herself.  She wanted to stop the seizure medications due to minimal residual pain.  I encouraged her to continue for the next few months, as this medication can keep those nerves suppressed that have been damaged by the virus.  There is inadequate information to be certain, but anti-viral and seizure medications and these injections may help prevent a long lasting condition after shingles called Post-Herpetic Neuralgia.  This condition has similar excruciating pain as shingles.  The rash will have faded long ago, but the pain is severe.  Most recently, there is a vaccine that helps prevent shingles.  Please consult your physician about this vaccine.  Early treatment with the other measures described is best once shingles occurs.  The location for numbing medication injection varies depending on the site of the rash, and is typically delivered by a specialty trained physician with x-ray guidance.

Ed McCluskey, MD

Pain Relief Specialists Northwest

www.prsnw.com

The Patient

She sits in a chair as I enter the room.  Though I have never met her before, I know her story all too well from many who have sat in that chair before.  She suffered a motor vehicle accident 5 years ago, and ultimately required a spine surgery to decompress a nerve root in her low back.  She had shooting pain down her leg and numbness, as well as occasional weakness before the surgery.  That all improved for several months after the surgery, but then she developed a flare up that led to another surgery.  She was unable to return to her job at the grocery store after that one, and finally had her most recent surgery 6 months ago.  She comes today reporting shooting pain down her leg with numbness, as well as occasional weakness.  She wonders out loud what went wrong, and complains that no one can find out what is wrong.  Her primary care does not want to prescribe pain medicines to her any longer, and her husband is upset that she is not getting better.

We continue the conversation as I detail her history in the computerized record.  I have learned to listen, create meaningful eye contact, and yet enter a constant flow of information into the computer.  She continues to answer my questions, “the pain is 8/10 on the bad days and I can hardly stand it….I wake up 4-5 X per night in pain and sometimes run out of my medication early….Do you think this is all in my head?  My husband does.”  I pull away from the keyboard and scoot my rolling stool near to her as I reassure her that pain that lasts this long is complicated.  Depression, anxiety and anger are often interwoven in chronic pain.  They complicate the ability to cope and impair recovery.  These need to be addressed, but they don’t mean that the pain isn’t “real”.  She tears up as I give affirmation to her feelings and alleviate her fear that she is “crazy”.

The physical exam shows no surprises.  I conclude that she has undergone appropriate surgical treatments, but unfortunately has developed scar tissue at the site of the original injury that is contracting around the nerve and resulting in aggravated symptoms.  This occurs in a certain percentage of spine surgeries and is known as post-laminectomy syndrome or failed spine syndrome.

I review with her in terms easily understood what I think is her diagnosis.  She understands that there is no cure for this, but that treatment will help her improve her quality of life.  The combination therapies that we term multi-disciplinary treatment are reviewed.  Initially, the medication options I recommended included continuing her pain medication, but in a time released form.  We would also be following her closely to assure that she took these according to the directions.  She signed an opiate agreement paper and an informed consent re: this part of her treatment.  I explained to her why seizure medications help with nerve pain such as she had.  Antidepressant medications also help with nerve pain as well as the depression that often accompanies chronic pain.

Spinal injections and even the future possiblity of a spinal cord stimulator were described, but her eyes showed fear as I talked about this, so we tabled it for another day.

She cringed when I brought up physical therapy, but I persisted in the explanation of its importance.  She had a bad experience in the past, but now understands that this will help her reactivate and retrain her nervous system. 

I described the intention to involve her in counseling re: chronic pain issues, and that this would be useful for her husband to be involved in as well.

The visit ended with prayer that she had requested.  She smiled as she walked out of the office with a slight limp.  “I have hope for the first time in a long time.”

Who of us could face another day without hope.  What a privilege it has been over the years to bring hope and relief to many people’s lives.  Sometimes, the therapies don’t work, but the compassion and caring are real and make a difference.

Don’t let your Pain Care get lost in the Reform Shuffle

The National Pain Care Policy Act has passed the House and now is in a Senate subcommittee.  It will likely sit there unresolved until the bigger health care reform debate is resolved.  Providers and patients alike need to acquaint themselves with this legislation and voice their support to the legislators. 

Additional attention needs to be paid to achieve funding for NASPER.  This is the National All Schedules Prescription Electronic Reporting that became law in the past, but was never funded.  The current version leaves it up to each state to implement this.  Unfortunately, the lack of interstate communication defeats the purpose in many locations.  Fully implemented, this system allows providers that prescribe controlled substances to access a database to determine if and when a patient under their care receives a controlled substance from another provider.  Knowledge of this will lead to the safer practice of medicine, and will decrease diversion and inappropriate use of controlled substances for non-medical use.  Concerns about the confidentiality of this information is valid, but should not rule the day.  With the rapid increase in pharmaceutical medication abuse, especially by the youth of America, we need more tools to help with appropriate prescribing.  Without this, proper pain care will be suppressed.

The FDA has been mandated by Congress to address prescription abuse, misuse, and diversion.  Though I support more effort in this area, I also am concerned that actions in this area could create more barriers to access.  Many physician colleagues in Oregon bristled at the legislature required mandate for continuing education in pain treatment.  The FDA has already stated that documentation of additional training for opiate prescribing will likely be included in their new efforts.  Some physicians will likely give up the privilege to prescribe these medications rather than submit to more training.  Many of my primary care colleagues already refuse to prescribe opiate medications for non-cancer pain.

Noridian, one of the carriers overseeing Medicare reimbursement for many states in the West, has proposed to stop coverage for lumbar facet injections, lumbar medial branch blocks, and lumbar medial branch block radio-frequency neurolysis.  This likely sounds like gibberish to most of you, but these treatments are a core tool for my specialty to treat one of the most common causes of back pain.  They are effective when applied in the right circumstances.  Noridian claims there is inadequate evidence for the effectiveness of these techniques.  If you have experienced the benefit from these, or are a practitioner who utilizes these techniques in your practice, now is the time to speak out.  You need to contact CMS prior to the end of the month to voice your opinion, preferably supported by medical literature.  Several entites have contact information and sample letters on their websites.  These include the American Academy of Pain Medicine, http://www.painmed.org; International Spine Injection Society, http://www.spinalinjection.com/; American Society of Anesthesiologists, http://www.asahq.org/; and American Society of Interventional Pain Physicians, http://www.asipp.org/index.html.

Thank you for assisting in this effort.

Ed McCluskey, MD

www.prsnw.com