tag:blogger.com,1999:blog-4968787219619380438.post7332606162925345730..comments2023-09-21T04:02:29.457-04:00Comments on Skeptical Scalpel: Pain is not the "5th vital sign"Skeptical Scalpelhttp://www.blogger.com/profile/13206922456661320751noreply@blogger.comBlogger42125tag:blogger.com,1999:blog-4968787219619380438.post-2303605765506914202017-09-11T12:28:35.207-04:002017-09-11T12:28:35.207-04:00Unknown, unintended consequences for sure.
Carol...Unknown, unintended consequences for sure. <br /><br />Carolyn, I should have been more specific. Yes, legitimate pain management clinics are a good thing. I should have said bogus pain clinics and "pill mills" have sprung up all over.<br /><br />I agree that alternatives for drugs can work and should be offered more frequently than they are. <br /><br />My experience and that of other doctors is that a lot of patients have unrealistic expectations about pain treatment. Yes, many expect complete relief of pain. A while ago, a Twitter follower posted a question from her hospital's patient satisfactory survey that asked "Did caregivers do everything they could to relieve *all* of your pain?"Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-64256595951791855962017-09-10T11:12:18.281-04:002017-09-10T11:12:18.281-04:00Hello Dr. Scalpel - you write "Pain managemen...Hello Dr. Scalpel - you write "Pain management clinics have sprung up all over the place" as if somehow that's a bad thing. <br /><br />As a person who regularly attends our hospital's Regional Pain Clinic (for refractory angina, coronary microvascular disease - following an MI in 2008), I can tell you that my pain specialists there are lifesavers. Period. <br /><br />One of my doctors (a GP-turned-anaesthetist-turned-pain specialist) has done a one-year fellowship in Sweden specifically studying coronary microvascular disease pain (a condition, by the way, that even some cardiologists don't know a lot about!) <br /><br />I'm able to function throughout the day only because of the many non-drug, non-invasive pain self-management tools I've learned about at this Clinic. Occupational therapists there work with us on simple and practical ways of moving that can help us. Many of the other people I've met at the Clinic have lived with unspeakably bad chronic pain every day that has not been even remotely addressed until now, often suffering for years. They do NOT expect to be, as you say, "completely pain-free" (not one patient in my Pain Clinic ever expects that!) - they just need occasional moments of lesser pain than usual. <br /><br />From a psychosocial perspective, living with untreated pain is exhausting, demoralizing and damaging. There is also an important and often underappreciated difference between drug addiction (a bad outcome) and drug dependence (a perfectly acceptable outcome for those living with chronic pain). <br /><br />If, instead of opioiod prescriptions, more docs could have offered Pain Clinic referrals to all those living with debilitating pain, maybe we wouldn't be in this opioid addiction mess now.Carolyn Thomashttps://myheartsisters.org/2014/09/14/brain-freeze-pain-self-management/noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-63148234298211435782017-09-09T20:34:18.679-04:002017-09-09T20:34:18.679-04:00Obviously this problem has more and more unintende...Obviously this problem has more and more unintended consequences. Recently saw the patient mentioned above with terrible failed back syndrome. On hydrocodone, stable dose 12 years. <br />Family doc retires and case is taken over by ARNP. Patient on the same dose of alprazolam and hydrocodone for 12 years. ARNP rapidly tapers both and tries to substitute remeron, ambien, gabapentin in high doses on top of his usual tegretol for a TBI seizure disorder. Patient falls asleep crashes car and fortunately not hurt. Yes there is a problem but like with any problem the fastest way out the problem is also the fastest way to get you back into trouble.<br />Just sayinAnonymoushttps://www.blogger.com/profile/07312766314888586389noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-78668923529919076612015-12-02T07:20:11.851-05:002015-12-02T07:20:11.851-05:00Jim, thanks for your comment and the link. It'...Jim, thanks for your comment and the link. It's a great article.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-50420398627486799572015-12-01T18:32:12.338-05:002015-12-01T18:32:12.338-05:00As a person with spina bifida who has had 55 surge...As a person with spina bifida who has had 55 surgeries, was on opioids for 18 years and off the past 16, I can appreciate this mess. I appreciate your views. Here are mine! http://www.indystar.com/story/opinion/2014/02/21/jimmy-ryser-addicts-are-set-up-to-die-by-todays-medical-standards/5709569/Jim Rysernoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-81163906142621297662015-11-09T07:29:19.640-05:002015-11-09T07:29:19.640-05:00Thanks, Christopher. It must be hard to tell how m...Thanks, Christopher. It must be hard to tell how much pain a 2 year old is having. Interesting comment about home medicine cabinets. I wonder what percentage of US homes have pain meds lying around. I'll bet it's well over 50%.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-85793090046141935092015-11-08T21:02:08.838-05:002015-11-08T21:02:08.838-05:00I've been a pediatric intensivist for 30+ year...I've been a pediatric intensivist for 30+ years and we have it better than you guys: our pain assessments are pretty much based on direct observation. If the child can tell us about their pain, great. But heart and respiratory rates and just plain looking at kids is the biggest thing. Also, kids don't fib or become manipulative about it. (Well, adolescents with other issues occasionally do). Those pediatric smiley face scales are mostly silly. With children it is also amazing how well distraction can work.<br /><br />Still, we're seeing in the PICU the same spike in narcotic overdoses from suicide attempts and gestures, often because so many home medicine cabinets now have narcotics in them. Anonymoushttps://www.blogger.com/profile/15501802823856630693noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-41633912484630583832015-10-22T21:04:44.232-04:002015-10-22T21:04:44.232-04:00Unfortunately, that doesn't seem to be happeni...Unfortunately, that doesn't seem to be happening.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-53787751428677706842015-10-21T11:56:04.343-04:002015-10-21T11:56:04.343-04:00Agreed Skep. We need people with common sense to m...Agreed Skep. We need people with common sense to make laws, guidelines and rules. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-50940947002456453812015-10-20T09:59:09.908-04:002015-10-20T09:59:09.908-04:00I appreciate your comments, but I cannot help the ...I appreciate your comments, but I cannot help the fact that my perspective is from that of a physician. I agree that pain relief is part of our job. But it seems like more and more people are blaming doctors for the opioid and heroin epidemics. As mentioned above, a state supreme court has ruled that doctors can be held liable for patients who become addicted to pain medication. This puts physicians in a very difficult position. I recently read that some doctors are saying they will not treat pain with any kind of narcotic. I think that will be difficult because the options for treatment are not great. <br /><br />I'm sorry you are suffering, but I did not create this mess. I am simply offering my opinion about it.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-2134745522845369062015-10-18T22:31:54.517-04:002015-10-18T22:31:54.517-04:00You may not be able to alleviate all pain, but sur...You may not be able to alleviate all pain, but surely there is some place for pain relief in the management of diseases and conditions that cause great physical suffering. Doesn't severe pain cause people physical stress, hamper their mobility, increase their likelihood for depression and suicidal ideation, decrease their ability to think and function effectively? Between all the modalities that can bring pain relief--including physical therapy, judicious use of medication as part of a plan to help people regain mobility, etc., you could present this "doctor dilemma" in a much more positive, patient-centered manner, and make these suffering individuals who are trusting you with their care feel less like burdens and more like active consumers and participants in helping to improve their own health. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-78984782825070728522015-08-07T07:16:55.466-04:002015-08-07T07:16:55.466-04:00Chris, great comments. You have summed up the dile...Chris, great comments. You have summed up the dilemma nicely. Factor in the new ruling by a West Virginia court that addicts may now sue doctors for enabling them. Here's a link to the post I wrote about it. http://skepticalscalpel.blogspot.com/2015/06/narcotic-addicts-can-sue-doctors-and.htmlSkeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-14621017417747208692015-08-06T18:14:21.309-04:002015-08-06T18:14:21.309-04:00I agree with you about the unreliability of pain a...I agree with you about the unreliability of pain as an objective measure. However, I think you are also correct in comments above that there are patients who are truly in pain who are suffering as a consequence of docs' increasing reluctance to prescribe pain medications. And at the same time we as docs are caught in a vice between the expectation that we assess and are responsive to standardized pain instruments (pain visual analogue scale, for instance), but at the same time prescribe no medications that will cause adverse consequences. <br /><br />As an example, a very typical patient encounter for me as a rheumatologist is a new patient who is 70+ and has a long-standing history of lumbar spondylosis, scoloiosis, and perhaps a few vertebral fractures due to osteoporosis. Most of them have already had kyphoplasty and/or fusion with instrumentation of multiple levels, which was done after failing several rounds of epidural steroid injections. They come to me because their PCP or back surgeon or pain specialist has said "maybe it's arthritis" (ha ha). Their pain scale is 10, but if I go by the books I really can't do anything for this geriatric patient with chronic pain because: A) tylenol doesn't work and causes liver damage, B) NSAIDs will cause kidney failure and ulcers, C) tramadol will cause seizures, D) Cymbalta/muscle relaxants/Lyrica/gabapentin will cause falls, E) tricyclic antidepressants will cause falls and arrhythmias, and F) opioids will cause dependence and constipation and overdose. I also get several referral per week for "my doctor prescribed hydrocodone to me at stable doses without adverse effects for 10 years, but now he says he can't prescribe it anymore because of new rules, but he said that you take it over now."<br /><br />I find the irony painful that the same people (CDC, CMMS, professional organizations) who keep pushing increasing reliance on standardized measurements of pain (and modification of treatment in response to those measurements) are also the same people who publish (often in the same publication) dire reports of the devastating consequences of any particular treatment for pain. I hate to be a skeptic, but mindfulness and tai chi are probably not going to be adequate to manage every patient with chronic non-cancer pain.Chris Wnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-46304530140786605972015-07-11T07:01:32.221-04:002015-07-11T07:01:32.221-04:00I usually do not post comments containing insults ...I usually do not post comments containing insults [see "Read This Before Commenting above], but I made an exception for anonymous above because I accepted his challenge.<br /><br />According to an article in MedPage Today [http://www.medpagetoday.com/Geriatrics/PainManagement/32971], the number of deaths per year caused by G.I. bleeding secondary to NSAIDs is 3200. That is about 20% of the number dying from narcotic overdoses every year.<br /><br />Here is a quote from the article. Lewis Nelson, MD, an emergency medicine and medical toxicology specialist in New York, said, "I could count 100 opioid-related problems for every nonsteroidal recognizable problem I see," Nelson said. "I literally don't see nonsteroidal problems and I see tons of opioid-related problems."<br /><br />The term "NSAID" does not even appear in my post. I do not know where the commenter got the idea that I was advocating NSAIDs for postsurgical pain relief. In fact, NSAIDs may be contraindicated because they can cause bleeding.<br /><br />The appropriate use of narcotic pain medication should not be discouraged. I recently wrote about a new law in West Virginia that would penalize doctors for enabling narcotic addicts. Unfortunately, this will cause doctors to think twice before prescribing these drugs for people who really need them. Here is the link to that post http://skepticalscalpel.blogspot.com/2015/06/narcotic-addicts-can-sue-doctors-and.html.<br /><br />To the anonymous commenter: If you want to discuss this in a civil way, I will be happy to post your response. An insult-filled diatribe will not be published.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-79739097032688704612015-07-10T21:07:54.611-04:002015-07-10T21:07:54.611-04:00Don't know the guy who wrote this but he's...Don't know the guy who wrote this but he's pretty typical of a dumb doc with scalpel in hand. I've run into plenty of them. They think that " If I can't fix it by slicing with a sharp knife, it's doesn't merit my attention". These types also tend to throw a ballistic temper tantrum if one should suggest otherwise. It is SO disappointing that these ignorant fools are allowed to practice medicine. I would challenge him to look up the number of people killed yearly by GI bleeds resulting from NSAID usage ( the anti-opioid doc's usual preferred medicine of choice for pain control). Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-54938815975047840792015-02-25T08:17:36.641-05:002015-02-25T08:17:36.641-05:00You suggestion is interesting but unlikely to be a...You suggestion is interesting but unlikely to be accepted by the general public. I'd rather focus on educating people about the realities of life. Now and then you are going to have some pain that cannot be completely alleviated by any drug. Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-66603320206555977762015-02-24T12:04:23.641-05:002015-02-24T12:04:23.641-05:00I'm most worried that drug overdose is now the...I'm most worried that drug overdose is now the current leading cause of accidental death in the U.S., with nearly 52% of the 44,000 deaths attributed to prescription painkillers (according to the CDC, 2013). As the number of painkiller prescriptions has tripled since the late 90's, so have the deaths. Perhaps most disturbing is that more than 3 out of 4 people who misuse prescription painkillers use drugs prescribed to someone else. These are the people I want to help and here is my solution-Require all patients to document their consumption of the drugs. So you want a refill? Great let's see a video with a time and date stamp proving you took all those pills. Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-28170999227023518632014-09-14T06:35:36.518-04:002014-09-14T06:35:36.518-04:00I appreciate your sharing that. There are many tha...I appreciate your sharing that. There are many that have pain that is not mechanical in nature. I've had shoulder manipulation and it's a discrete sort of pain as you mention. I asked my question because I think that there are people who don't experience certain types of serious and/or unrelenting pain that just are unable to understand the pain of others, different kinds of pain, pain that never goes away.Sherrynoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-77744878189003094772014-09-13T14:33:37.936-04:002014-09-13T14:33:37.936-04:00I don't have pain. I had rotator cuff shoulder...I don't have pain. I had rotator cuff shoulder surgery about a year ago. Took about 6 Percocets during the first 3 days. (http://skepticalscalpel.blogspot.com/2013/10/on-wrong-side-of-knife.html)<br /><br />I went to physical therapy twice a week for 4 months where the therapist manipulated my arm. The pain was excruciating because the shoulder had become very stiff due to the immobilization required. I didn't take anything for it because it stopped shortly after each manipulation.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-56562437797511199222014-09-13T01:53:28.482-04:002014-09-13T01:53:28.482-04:00People that see their doctors in their offices are...People that see their doctors in their offices are being treated as drug seeking. That's wrong, most of the time. Do you have pain? Or does it matter because you will always have doctor friends who will write for what you need? I'm curious because I learned over the years that the most compassionate doctors have been patients first. Sherrynoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-50130203520313401512014-09-12T08:20:17.411-04:002014-09-12T08:20:17.411-04:00Sherry, if you still believe that pain is what the...Sherry, if you still believe that pain is what the patient says it is, you haven't been in an ED recently. Lots of drug seekers show up in EDs complaining of pain. If they all received opioid prescriptions, the drug abuse epidemic would be much worse.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-7882062326847839702014-09-11T21:29:53.456-04:002014-09-11T21:29:53.456-04:00I entered the field in the time when "pain is...I entered the field in the time when "pain is what the patient says it is." I still believe that. The whole concept of pseudoaddiction is iatrogenic. As I've gotten older I have more pain. I rarely get a thing for it because my doctor sports the attitude of the young and unbroken. She, and many other doctors, will figure it out when they are no longer relevant. It will be too late. I think that the actions of the DEA are overreaching. I didn't mention that I am also a Certified Death Midwife and a strong supporter of the Death Cafe. We need more compassion and more trust. There are always folks willing to game the system but it's not the majority. As to the Tylenol comment earlier in the thread that med does NOT belong in every other med. That's fixable if unpopular.Sherrynoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-83494898681132646082014-09-11T19:13:19.379-04:002014-09-11T19:13:19.379-04:00Sherry, sorry about your vision. Thanks for commen...Sherry, sorry about your vision. Thanks for commenting. Postop patients are really not the issue most of the time. The real problem is pain without an obvious cause and no way to be sure how bad it is.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-76036867228518959082014-09-11T16:34:12.865-04:002014-09-11T16:34:12.865-04:00I am a nurse, disabled and retired due to vision l...I am a nurse, disabled and retired due to vision loss, of 23 years. I saw those ortho patients whose doctor claimed he had structurally fixed the patients so they didn't need much in the way of narcotics. I sense no empathy for the patients. Also, an aging population will have more pain. Do you have pain? Not everyone is stoic and, for the most part, I find that it's a good practice to listen to patients and let them define their experience.Sherrynoreply@blogger.comtag:blogger.com,1999:blog-4968787219619380438.post-84270355716071428182014-09-11T13:10:33.053-04:002014-09-11T13:10:33.053-04:00Sherry, I don't know what you mean by "ja...Sherry, I don't know what you mean by "jade." I retired about two years ago. I feel sorry for the patients who have real pain because they are the ones most affected by the shift toward prescribing less pain medication and the upcoming reclassification of hydrocodone/acetaminophen as a schedule II drug.<br /><br />Michael, I understand your point. It's not going to be easy to fix this.Skeptical Scalpelhttps://www.blogger.com/profile/13206922456661320751noreply@blogger.com