Sunday, March 21, 2010
Photo Credit Eva Kocher
First, let me state unequivcally that I am against all varieties of pain, foreign and domestic. Indeed, I wish that we could snuff the varmint out every time and place it surfaces. Pain is a wily opponent that can be difficult to vanquish. In recent years, physicians have been resorting to a ‘shock and awe’ strategy of using excessive force against it. While this may be sound military strategy, in the medical arena it has led to unintended and predictable consequences. I think that we physicians are pulling the narc trigger too quickly and too often.
It’s easy to advocate for a more parsimonious approach to pain control, when your humble blogger is pain free. Indeed, my own pain threshold cruises at low altitude, and has never been fairly tested. While this may limit my credibility, I maintain as a physician that my profession, including me, needs some narc reform.
When I was in medical training, during the days when my kids insist that I took the pet stegosaurus out for a walk, we prescribed narcotics for serious pain. Of course, all pain is serious, if you are the sufferer. Nevertheless, in those days we prescribed morphine, and its cousins, in specific clinical situations. We prescribed them in patients who were enduring the agony of kidney stones, myocardial infarctions, intestinal obstructions, acute abdomens, traumatic musculoskeletal injury and post-operatively. These medicines, in general, were reserved for acute pain. This bedrock medical practice has not changed.
Additionally, in those days, we physicians were taught to refrain from prescribing narcotics to manage chronic pain, in order to avoid causing medication addiction. Some doctors were also concerned that writing prescriptions for controlled pain medicines would invite scrutiny from medical boards and other oversight institutions. As the medical speciality of Palliative Care developed, physicians were reeducated that narcotic medications had a necessary role in the treatment of chronic pain, particularly in patients who were suffering from a terminal illness. Palliative Care taught us that we had been overly dogmatic and we needed to loosen up.
Another medical specialty, Pain Management, has emerged in recent years that treats patients with all sorts of chronic pain, often without a specific diagnosis. Gastroenterologists, for example, refer patients with unexplained abdominal pain to these specialists, not for diagnosis, but to manage the pain. This is is tough specialty, as the bulk of their practices are chronic pain patients, most of whom have exhausted other therapeutic alternatives. For many of them, these pain doctors are their last best hope.
Enter Morphine Mission Creep. When I was an intern, gazing out the window at flying pterodactyls, physicians didn’t prescribe enough pain medicines. Now, we have more than made up for our prior pharmacologic stinginess by turning the narcotic hose on full blast. Physicians now prescribe addictive and powerful narcotics routinely to patients with a variety of chronic painful conditions, particularly in the hospital. I witness this regularly on my hospital rounds, and am sure that other physicians can corroborate this observation. Patient come to the emergency room, often already on narcotics, complaining of breakthrough pain. The emergency room physician will then prescibe a stronger agent to be administered intravenously (IV) every 2 or 3 hours. This narc cycle goes on for several days. These folks are so tolerant (‘immune’) to narcotics, that they require high doses to achieve pain relief. Often, these patients will complain that even high doses at frequent intervals are not sufficient. Many of these individuals are truly experiencing pain, although nurses and physicians often observe that some of them seem too comfortable to warrant IV narcotics.
It is now common, for example, to medicate patients with chronic abdominal pain – stomach aches – with IV dilaudid, a powerful and addictive narcotic. Unlike acute pain, which will terminate, chronic pain lives on. Therefore, if a physician opts to prescribe addictive medicines to these patients, then what is the exit strategy? When we physicians go narc, we create an expectation that the patient’s ongoing condition needs narcotics.Over time, the patient becomes tolerant and addicted to these medicines. In many instances, the narcotic dependence and addiction becomes a much more serious disease than the original illness.
The medical profession needs to pull back from fostering narcotic ‘free love’. We all agree that the enemy is pain. Physicians should remain devoted to our mission to relieve pain and suffering in our patients. In many instances, we have been giving patients the wrong tools for the job. I’m not suggesting we adopt a narcotics moratorium on chronic pain, but that we be more judicious about their use. New specialties and medical expertise in pain management and control have many strategies and techniques that can be safer alternatives to chronic narcotics. We need to learn about them from our colleagues.
When we physicians held back pain medicines decades ago, we were wrong. I don’t think that we have it quite right yet.
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Posted by Michael Kirsch, M.D. at 8:37 AM
Labels: Medical Quality